m 


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College  of  l^l\v^itim^  anti  ^utgeong 


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1918 


Gtor, 


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chaustive 
either  in 

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i  on  the 
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le  Dis- 


pv 


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3rms  yet 
lysicians 
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of  rmiaaeipnia;  Jimiiur  oi  ••  v^yuiuiuui 
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No.  1. — Essentials  of  Physiology,    second  editton.   illustuated,  kevised 

AN»  ouE.-vTLY  ENLAKOED.  Bs'JI.  A.  Hahe,  M.1>.,  Clinical  rrofesi^or  of  Diseases 
of  Chiktren,  University  of  Pennsylvania,  i>enionstrator  of  TJierapeutles  and 
Instinctor  in  Phxsical  Diagnosis  in  the  Medical  Deparhnent.  and  In.struetor  in 
J'hysioio.i;y  in  the  Jiiological  Department,  of  the  University-  of  J'enusylvania, 
etc.,  etc- 

No.  2.— Essentials   of  Surgery.    Containing  also,   Surgieai  Landviarks, 

Minor  and  Operative  Surgery,  and  a  Cainplete  Deseription,  together  with  full  illns- 
tration  of  the  IJandkerehief  and  Roller  Bandage.  yKCOND  KuiTiON,  ^^•TT^  NHSETY 
Illustrations,  liy  Edward  JNIartin,  jM.  D.,  iriStrnctoi-  in  (ij^'-rative  Snrgery 
and  Lecturer  on  JNIinor  Surgery,  University  of  Fenns^•l^■:^lia  :  Surgeon  to  the 
()ut-Paticnt«'  Department  of  the  Children's  Hospital,  and  Suigical  Kegister  of 
the  Philadtilphia  Hospital,  etc.,  etc. 

No.   3.— Essentials    of   Anatomy,    including,    ]'isce^ai  Anatomy,   based 

UPON  THE  LAST  EDITION  OP  (iRAY.  SECOND  EDITION.  Ovcr  t  luce  hundri-il  and  lifty 
p:iges,  with  on(;  hundred  and  seventeen  Illustrations.  Uy  Cha.s.  JJ.  Nancredk, 
M.'  D.,  Professor  of  Surgery  and  Clinical  Surgery-  in  the  ITniversit^-  of  Michigan, 
Ann  Arbor;  Corresponding  Member  of  the  Koyal  Academy  of  Medicine,  Koine, 
ItJily ;  Laic  Surgeon  Jclfcrsou  Medical  College,  etc.,  etc. 

No.  4. — Essentialsof  Medical  Chemistry,  organic  and  inorganic,  contain- 
ing also  Duestions  on  Medical  Phy.sics,  Chemical  Phy-iology,  Analyiical  Pro- 
cesses, Urin:ilysisandToxicok»gy.  fourth  thousand.  P.y  liAWUENCF.  Wolpe,  ]\l.l>.. 
Demonstrator  of  Chemistrv,  jellersou  Medical  College;  Visiling  Thysician  to 
(kirrnau  Jlospilal  of  Philadelphia;  Member  of  rhiladdithia  College  oi  I'liar- 
macy,  etc.,  etc. 

No.  5. — Essentials  of  Obstetrics,    illustratkd.  Four.TUTTioirsAND.  i;y  ^\ . 

i.astrrly  Ashton,  M.  D.,  l)<'.n)onstrator  of  Clinicat  Obstctricsin  the  .fetlersc.n 
Medical  Coll<!gc,,  and  Chief  of  CUnics  for  Diseases  of  Women  in  the  JefTersou 
Medical  Hospital,  etc.,  etc. 

No.  6.— Essentials  of  Pathology  and  Morbid   Anatomy.     iiiusirat(  1 

I'.yC.  K.  ARMANI)  SKwrLic,    P..A.,   M.P,.   Cantab.,   L.S.A.,  M.lt.C.P.,   I>ond.,  I'hysi 

ian   10  the  Nort,h<;asteru   Hospital  for  Children,  Hackney;  Professor  o  I    Vocal 

md   Aural  Physiology  and  Exaniiuerin  Acoustics  at  Trinity  College,  London, 


LIST  OF  COIVIPENDS.— Continued. 


No.  7. — Essentials  of  Materia  Medica,  Therapeutics  and  Prescription 

Writing.  IJj^IIknuy  JMoiiuis,  JNJ.D.,  lule  Demonstrator,  JelTerson  Medical  Col- 
lege^  FelJow  College  ol  I'liyslciaiis,  riilladelphla;  Co-Editor  Biddle's  Materia 
MediCii;  Visiting  riiysician  to  Si.  J osei)h',s  Hospital,  etc,  etc. 

Nos.  8   and  9 —Essentials  of  Practice  of  Medicine.     (Double  number, 

over  live  hundred  i)ageH.)  15}'  Henry  Morris,  M.D..  Author  of  Essentials  of 
Materia,  Medica  and  Therapeutics,  etc.,  etc. 

No.  10. — Essentials  of  Gynaecology,     w  ith  umnerons  illustrations.   By 

Edwin  IJ.  Craigin,  M.D.,  Attending  Gyna?oo]ogist,  Jioosevelt  Hospital,  Out- 
patients' Department;   Assistant  Surgeon,  New  York  Cancer  Hospital,  etc.,  etc. 

No.  II. — Essentials  of  Diseases  of  the  Skin.     75  h lustrations.   By  Henry 

W,  Stbl WAGON,  M  I).,  Clinical  Lecturer  on  Dermatology  In  ihe  Jetferson  Medical 
College,  Philadelphia;  rhysician  to  riiiladelphia  Dispensary  for  Skin  Diseases; 
Chief  of  the  Skin  Dispensaiy  in  the  Hospital  of  University  of  Pennsylvania; 
Physician  to  Skin  Department  of  the  Howard  Hospital;  Lecturer  on  Derma- 
tology in  the  Women's  Medical  College,  Pliiladelphia,  etc.,  etc. 

No.  12. — Essentials  of  Minor  Surgery  and  Bandaging.     Wiihan  Appen 

dix  on  Venereal  Diseases.  Illustrated.  By  Edward  Martin,  M.D.,  author  of 
the  "Essentials  of  Surgery,"  etc.,  etc. 

No.  13, — Essentials  of  Legal  Medicine,  Toxicology  and  Hygiene,     one 

hundred  and  thirtv  line  Illustrations.  By  C.  E.  Armand  Semple,  M.  D.,  Author 
of  "Essentials  of  Pathology  and  JNIorbid  Anatomy,"  etc.,  etc. 

No.  14.— Essentials  of  the  Refraction  and  Diseases  of  the  Eye.    luus 

trated.  By  Edward  Jackson,  A.M.,  M.D.,  Professor  of  J>iseases  of  the  Eye  in 
the  Philadelphia  Polyclinic  and  College  for  Graduates  in  Medicine;  Member  of 
the  American  Ophthalmological  Society;  Eellow  of  the  College  of  Physicians 
of  Philadelphia;    Fellow  of  the  American  Academy-  of  Medicine,  etc.,  etc,  and 

Essentials  of  Diseases  of  the  Nose  and  Throat,    illustrated.   By  p:.  Bald 

win  GLBA.SON,  M.D.,  Assistant  in  the  Xose  aiui  Throat  Dispensary  of  the  Hospital 
of  the  University  of  Pennsylvania;  Assislant  in  the  Xose  and  Throat  Depart- 
mentof  the  Union  Dispensary;  Member  of  the  German  Medical  Society,  Phila- 
delphia, Polyclinic  Medical  Society,  etc.,  etc.  .  *^ 

No.    15.— Essentials  of  Diseases  of  Children,    illustrated.   By  William 

M.  Powell,  M.D.,  Physician  to  the  Clinic  for  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania;  Ex.imining  Physician  to  the 
Children's  Seashoi-e. House  for  Invalid  Children  at  Atlantic  Citjv  J^"-  -L:  form- 
erly instructor  in  Physical  Dia<i-nosJs  in  th(^  Medical  Department  of  the  Univer- 
sity of  Pennsj-lvania,  and  Chief  of  the  Medical  Clinic  of  the  Philadelphia  Poly- 
clinic. 

No.  16. — Essentials  of  Examination  of  Urme,  colored  "Vogel  scale  ' 

and  numerous  Illustrations.  By  Laavhence  \\'olfp,  M.D.,  Author  of  "  Essentials 
of  Chemistry,"  etc.,  etc.;  price,  75  cents. 

No,  17.  Essentials  of  Diagnosis.  By  Davtd  D.  Stewart,  M.D.,  Lecturer 
on  Diseases  of  the  Xervons  Sj'stem  at  the  jetleraon  JSledical  College:  Late  Chief 
of  the  Medical  Clinic  Jefleison  IMedical  College  Hospital;  Physician  to  St. 
Mary's  and  St.  Christopher's  Hospitals;  Fellow  of  the  College  of  Physicians  of 
Philadelphia,  etc.,  etc.  (in  press). 

At  the  present  time,  when  the  student  is  forced  by  the  rapid 
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part  to  master  it,  a  book  which  contains  the  "' essentials"  of 
a  science  in  a  concise  yet  readable  form  must  of  necessity  be 
of  value. 

Intended  to  assist  Students  to  put  together  the 

knowledge  they  have  already  acquired 

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Anatomy  and  Practical  Dissector. 

BY 

Professor  of  Surgery  and  Clinical  Surgery  in  the  University  of  Mich- 
igan, Ann  Arbor ;    Corresponding  Member  of  the  Royal 
Academy   of   Medicine,    Rome,    Italy;    Late 
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IN    PREPARATION. 

DISEASES  OF  WOMEN, 

BY 

HEIVRY  J.  OARRIOXJES.,  A..M:.,  M:.r>. 

Professor  of  Obstetrics  in  the  New  York  Post-Graduate  Medical  School 

and  Hospital ;  Gynaecologist  to  St.  Mark's  Hospital  in  New  York 

City;  Gynaecologist  to  the  German  Dispensary  in  the  City  of 

New  York ;  Consulting  Obstetrician  to  the  New  York  Infant 

Asylum;  Obstetric  Surgeon  to  the  New  York  Maternity 

Hospital:   Fellow  of  the  American  Gynaecological 

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Medicine ;  President  of  the  German  Medical 

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READY  SHORTLY. 

DISEASES  OF  THE  EYE. 

BY 

OEO,  E.  r>e  SCPI\^EI]VITZ,  M!.  I>. 

Ophthalmic  Surgeon  to  Children's  Hospital  and  to  the  Philadelphia 

Hospital ;  Ophthalmologist  to  the  Orthopaedic  Hospital 

and  Infirmary  for  Nervous  Diseases,  etc. 


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A  NEW 


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Nos.  8  and  9.— Essentials  of  Practice  of  Medicine.  (Double  num- 
ber, over  live  hundred  pages.)  By  Henry  Morris,  M.D.,  Author  of  Es- 
sentials of  Materia,  Medica  and  Therapeutics,  etc.,  etc. 

No.  10.— Essentials  of  Gynaecology.  With  numerous  illustrations. 

By  Edwin  B.  Craigin,  M.D.,  Attending  Gynajcologist,  Roosevelt  Hos- 
pital, Outpatients  Department;  Assistant  Surgeon  Xew  York  Cancer 
Hospital,  etc.,  etc. 

No.  II.— Essentials  of  Diseases  of  the  Skin.   75  illustrations.  By 

Henry  W.  Stelwagon,  M.  D.,  Clinical  Lecturer  on  Dermatology  in  the 
Jetrerson  Medical  College,  Philadelphia;  Physician  to  Philadelphia  Dis- 
pensary for  Skin  Diseases  ;  Chief  of  the  Skin  Dispensary  in  the  Hospital 
of  University  of  Pennsylvania;  Physician  to  Skin  Department  of  the 
Howard  Hospital;  Lecturer  on  Dermatology  in  the  Women's  Medical 
College,  Philadelphia,  etc.,  etc. 

No.  12.— Essentials  of  Minor  Surgery  and  Bandaging,    with  an 

Appendix  on  Venereal  Diseases.  Illustrated.  By  Edward  Martin, 
M.  D.,  author  of  the  "Essentials  of  Surgei-y,"  etc.,  etc. 

No.  13.— Essentials  of  Legal  Medicine,  Toxicology  and  Hygiene. 

One  hundred  and  thirty  finelllu^trations.  By  C.  E.  Armand  Seitple,  M.D., 
Author  of  "Essentials  of  Pathology  and  Morhid  Anatomy,"  etc.,  etc. 

No.  14. — Essentials  of  the  Refraction  and  Diseases  of  the  Eye. 

Illustrated.  By  Edward  Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of 
the  Eye  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in  Medi- 
cine ;  Member  of  the  Am':;rican  Ophthalmological  Society  :  Fellow  of  the 
College  of  Physicians  of  Philadelphia;  Fellow  of  the  American  Academy 

ofMedicine,ete..etc.,and  Essentials  of  DIseasesofthe  Nose  and  Throat. 

Illustrated.  By  E.  Baldwin  Gleason,  M.  D..  Assistant  in  the  Nose 
and  Throat  Dispensary  of  the  Hospital  of  the  tJniversity  of  Pennsylva- 
nia ;  Assistant  in  the  N"ose  and  Throat  Department  of  the  Union  Dispen- 
sary; Member  of  the  German  Medical  Society,  Philadelphia,  Polyclinic 
Society,  etc.,  etc. 

No.    15.— Essentials   of  Diseases   of   Children,    illustrated.    By 

William  M.  Powell,  M.  D.,  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania ;  Examining 
Physician  to  the  Children's  Seashore  House  for  Invalid  Children,  at  At- 
lantic City,  N.  J. ;  formerly  Instructor  in  Physical  Diagnosis  in  the 
Medical  Department  of  the  University  of  Pennsylvania,  arid  Chief  of  the 
Medical  Clinic  of  the  Philadelphia  Polyclinic. 

No.   16. — Essentials  of  Examination  of  Urine,    colored  "  Vogel 

Scale,"  and  numerous  Illustrations.  By  Lawrence  Wolff,  M.D.,  author 
of  "  Essentials  of  Chemistry,"  etc,,  etc.;  price,  75  cents. 

No.  17. — Essentials  of  Diagnosis.  By  David  D.  Stewart,  m.  d. 
Lecturer  on  Diseases  of  the  Nervous  System  at  the  Jefferson  Medical 
College;  Late  Chief  of  the  Medical  Clinic  .Jefferson  Medical  College  Hos- 
pital ;  Physician  to  St.  Mary's  and  St.  Christopher's  Hospitals  ;  Fellow  of 
the  College  of  Physicians  of  Philadelphia,  etc.,  etc. 

No.    18. — Essentials  of  the    Practice  of  Pharmacy.    By  l.  e. 

Sayre,    Professor  of  Pharmacy  and  Materia  Medica  in  the  University 
of  Kansas. 
For  Sale  by  all  booksellers. 

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—AND— 

MANUAL  OF  PRACTICAL  DISSECTION, 

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OVER   200   ILLUSTRATIONS. 


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SAUNDERS'  QUESTION-COMPENDS.  No.  2. 


ESSENTIALS  OF  SURGERY, 


TOGETHER   WITH    A 


FULL  DESCRIPTION  OF  THE  HANDKERCHIEF 
AND  ROLLER  BANDAGE. 


AEBANGED  IN   THE  FORM   OF 


QUESTIONS  AND  ANSWERS 

PKEPARED   ESPECIALLY   FOE 

STUDENTS  OF  MEDICmE. 


BY 

EDWARD  MAETIN,  A.M.,  M.D., 

IHBTEIJCTOB    OF    OPERATIVE    SUEGERY,  TJNIVEESITT  OF    PENNSYLVANIA  ;    SUEGKON    TO    THE 

HOWARD  hospital;   SURGEON   TO  THE   OUT-PATIENT  DEPARTMENTS   OF 

THE    UNIVERSITY   AND    CHILDREN'S    HOSPITALS. 


SECOND  EDITION.    WITH  NINETY  ILLUSTRATIONS. 


PHILADELPHIA: 

W.   B.    SAUNDER 

913  Walnut  Street. 

1890. 


Entered  according  to  Act  of  Congress  in  the  year  1888,  by 

W.   B.   SAUNDERS, 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


PREFACE. 


As  one  thrown  yearly  in  contact  with  large  numbers  of 
medical  students,  and  familiar  with  the  furious  rate  at  which 
they  are  driven,  the  writer  feels  assured  that,  under  our 
present  system  of  rapid  education,  outline  works  are  of  dis- 
tinct value.  Third  year  men  who  attend  six  lectures  and 
two  clinics  daily  have  no  time  for  reading,  no  time  for  sys- 
tematizing their  knowledge  on  any  one  subject.  This  work 
must  either  be  done  for  them,  or  left  undone.  The  author 
has  carefully  gone  over  the  subject  of  Surgery,  and  has  en- 
deavored to  emphasize  the  essential  points  as  a  framework 
upon  which  more  detailed  knowledge  may  be  hung.  Agnew, 
Ashhurst,  Gross,  Walsham,  Tillmann,  Kbnig,  Treves,  Weir, 
Smith,  Gerster,  and  many  others  have  been  freely  consulted. 
The  table  of  Urinary  Calculi  is  taken  direct  from  MouUin's 
article  in  Treves's  manual.  The  classification  of  Yenereal 
Diseases  follows  that  of  White  (University  of  Pennsylvania), 
To  Mr.  W.  L.  Alrich  and  Mr.  Daniel  Webster  thanks  are 
due  for  their  valuable  assistance. 

The  author  has  made  an  earnest  effort  to  be  accurate, 
concise,  and  modern. 

E.  M. 

October  10, 1888. 

(vii) 


CONTENTS. 


PAGE 

Inflammation       .........  17 

Abscess 27 

Ulceration 31 

Mortification        • 38 

Wounds 44 

The  germ  theory  of 44 

Shock    .         . .         '45 

Wound  fever 47 

Erysipelas 50 

Tetanus .        •        .52 

Hydrophobia 54 

Glanders 55 

Malignant  pustule 55 

The  healing  of  wounds 56 

The  treatment  of  wounds 57 

Wounds  of  arteries 73 

Wounds  of  nerves 75 

Head  injuries         .        . 75 

Injuries  of  the  meninges  and  brain      ....  81 

Concussion  and  contusion 83 

Compression 84 

Intracranial  inflammation 85 

Cerebral  localization    .        .        .^ 87 

Wounds  of  the  face      .        .       • 90 

Wounds  of  the  neck 91 

Wounds  of  the  chest 92 

Wounds  of  the  abdomen 95 

Burns  and  scalds 102 

(ix) 


X  CONTENTS. 

PAGE 

Fractures 105 

Special  fractures 112 

Luxations  or  dislocations 137 

Special  luxations 140 

Sprains         .         .         ..,...,.  158 

Wounds  of  joints 159 

Synovitis      .         .         . 160 

Arthritis       . 161 

Coxalgia       .        . .  163 

Sacro-iliac  disease 166 

White  swelling  of  the  knee-joint 166 

Eheumatoid  arthritis   .         .        .         .        ••      .        .        .  167 

Loose  bodies  in  joints 167 

Anchylosis .         .        .  168 

Diseases  of  bones         .        .        c 169 

Periostitis      .         .         .         .         .         .        ,        .         .169 

Osteitis  .         .         .         .         .         .         .         .        .170 

Osteomyelitis         . 170 

Abscess  of  bone    . 171 

Caries .         .        .         .172 

Necrosis 172 

Tubercle .173 

Syphilitic  bone  disease 173 

Osteomalacia         .        .        .        ...        .        ...  174 

Pott's  disease 174 

Rickets         .         . 176 

Hsemophilia          .        .         .         .         .         .         .         »        .  177 

Struma .         .         .  177 

Curvature  of  the  spine                  177 

Hernia .         .179 

Special  hernias 188 

Intestinal  obstruction 196 

Diseases  of  the  anus  and  rectum          .        .         .        .        .  198 

Syphilis 206 

Chancroid 210 

Gonorrhcea 211 


CONTENTS.  XI 

PAOK 

Urethral  deformities 217 

Stricture  of  the  urethra       . 217 

Diseases  of  the  prostate 224 

Affections  of  the  bladder 227 

Rupture  of  the  bladder 227 

Exstrophy  of  the  bladder 227 

Cystitis .  228 

Atony  and  paralysis  of  the  bladder      ....  229 

Hsematuria 229 

Retention  of  urine 230 

Stone  in  the  bladder      .    * 233 

Hydrocele     .        . 238 

Hsematocele 239 

Varicocele    .        .        .    ' 240 

Sarcocele 240 

Diseases  of  veins 242 

Angioma 244 

Aneurism 245 

Diseases  of  the  lymphatics  .        ; 248 

Effects  of  cold      .         .         . 249 

Foreign  body  in  the  air-passages 250 

Affections  of  the  oesophagus 251 

Surgical  affections  of  the  breast 253 

Club-foot 254 

Hare-lip  and  cleft  palate      , 255 

Diseases  of  bursse  and  tendons 256 

Bursitis  .        .        .         .        .        .        .        .        .256 

Onychia 257 

Anaesthetics 258 

Ligation  of  arteries 261 

Excision  of  joints 278 

Amputations 282 

Bandaging 290 

The  roller  bandage 290 

Head  bandage 299 

Handkerchiefs 301 


ESSENTIALS  OF  SURGERY 


INFLAMMATION. 

What  is  inflammation? 

Inflammation  is  a  perversion  of  nutrition  attended  with  red- 
ness, heat,  swelling,  pain,  and  a  tendency  to  exudation. 

Name  the  varieties  of  inflammation. 

1.  Acute.     2.  Chronic. 

Name  the  causes  of  inflammation. 

1.  Predisposing,  Anythinoj  lowering  the  powers  of  resistance, 
such  as  heredity,  age,  sex,  occupation,  habits,  food,  previous  in- 
flammation, temperature,  climate,  temperament,  mental  con- 
dition. 

2.  Exciting.  Traumatism,  heat,  cold,  acids,  alkalies,  micro- 
organisms and  their  products. 

How  does  inflammation  extend  ? 

By  the  means  of  bloodvessels  or  lymphatics.  Extension  by 
continuity,  contiguity,  metastasis,  and  sympathy  is  really  due  to 
either  the  blood  or  lymph  vessels. 

How  may  inflammation  terminate  ? 

1.  Resolution,  or  return  of  tissues  to  their  normal  condition. 

2.  Organization,  or  new  formation. 

3.  Death  of  tissue,  by  suppuration  or  mortification. 

What  are  the  phenomena  of  inflammation  ? 

1.  Disturbed  innervation,  causing,  first,  a  contraction  of  the 
capillaries,  followed  shortly  by  a  paralytic  dilatation  producing 
active  hypersemia. 
2 


18  ESSENTIALS    OF    SURGERY. 

2.  Alteration  in  the  bloodvessels  and  contents.  The  vascular 
walls  are  widely  dilated,  plastic,  and  their  epithelium  greatly 
swollen.  The  white  blood  corpuscles  are  numerous,  cling  to  the 
sides,  and  the  current  is  slowed  or  stopped.  The  red  corpuscles 
stick  together  ;  the  liquor  sanguinis  contains  more  fibrin  forming 
elements. 

3.  JExudation  or  passage  through  the  walls  of  white  corpuscles 
(diapedesis)  and  liquor  sanguinis. 

4.  Alteration  in  the  perivascular  tissue.  Intercellular  matrix 
undergoes  mucoid  softening,  connective-tissue  corpuscles  pro- 
liferate, the  exudate  coagulates. 

What  zones  are  found  about  an  inflamed  area  ? 

Most  peripherally,  a  bright  red  ring  where  the' bloodvessels 
are  widened,  called  the  zone  of  determination.  Within  this  an 
area  in  which  from  overcrowding  the  blood  current  is  slow,  the 
color  here  is  somewhat  dusky,  this  area  is  called  the  zone  of 
congestion.  Centrally,  an  area  where  the  blood  current  is  prac- 
tically at  a  stand-still,  this  is  the  focus  of  inflammation,  and  is 
termed  the  zone  of  stasis. 

What  are  the  stages  of  inflammation? 

First  stage.     Acute  hypercemia  with  slight  exudation. 

Second  stage.  Lymphatization  or  free  exudation  and  the  for- 
mation of  plastic  lymph. 

Tliird  stage.  Suppuration  or  formation  of  pus  due  to  the  death 
of  white  blood  corpuscles  and  their  fibrinous  trabeculse. 

What  is  plastic  lymph? 

The  exudate  of  acute  inflammation.  It  is  made  up  of  white 
blood  corpuscles  and  proliferated  connective-tissue  cells,  im- 
bedded in  a  frame-work  of  coagulated  fibrin. 

Name  the  different  kinds  of  exudate. 

1.  Serous.  '  Thin,  non-organizable.  Examples :  hydrocele, 
ascites,  hydrothorax. 

2.  Fibrinous.  Contains  much' fibrin,  coagulates,  and  readily 
undergoes  organization. 


INFLAMMATION.  19 

How  may  the  various  stages  of  inflammation  terminate? 

Active  hyperaemia  may  terminate  in  resolution  or  in  exudation. 

Exudation  may  terminate  in  resolution,  organization,  or  sup- 
puration. 

Suppuration  may  terminate  in  granulation  or  in  death  of  the 
part. 

Describe  resolution. 

The  dilated  vessels  again  contract,  the  white  blood  corpuscles 
begin  to  move  away  from  the  inflamed  area  as  circulation  is 
restored.  The  migrated  corpuscles  either  return  to  the  blood- 
vessels, degenerate,  and  are  carried  oflf  by  the  lymphatics,  or 
remain  as  fixed  connective-tissue  corpuscles.  The  fibrin  becomes 
granular  and  is  absorbed. 

Describe  organization. 

I^ew  bloodvessels  are  formed  in  the  exudate  by  looping  of 
the  old  ones ;  these  loops  anastomose  with  each  other,  forming 
a  network.  In  addition  new  vessels  are  separately  developed 
in  the  inflammatory  tissue  which,  in  turn,  anastomose  with  the 
previously  existing  vessels.  If  the  irritation  ceases  many  of  the 
exudation  cells  disintegrate  and  are  removed,  others  are  con- 
verted into  connective-tissue  corpuscles,  which,  by  their  contrac- 
tion, obliterate  the  new  bloodvessels  and  form  cicatrices. 

Describe  suppuration. 

If,  from  great  irritation,  the  exudation  is  excessive  there  will 
be  acute  starvation,  with  disintegration  of  the  central  portions 
from  occlusion  of  the  supplying  bloodvessels.  If  this  dead 
central  portion  be  kept  aseptic  it  may  be  absorbed ;  if,  however, 
any  of  the  pyogenic  organisms  gain  access  to  it  they  keep  up 
the  irritation,  cause  additional  effusion,  and  produce  suppuration. 

What  is  pus  ? 

Pus  is  the  product  of  suppuration.  It  is  a  creamy  looking, 
highly  albuminous  liquid,  sp.  gr.  1030,  and  contains  fat,  blood 
salts,  tyrosin,  leucin,  and  other  nitrogenous  derivatives.  On 
standing  it  separates  into  liquor  puris^  a  clear  liquid,  practically 
the  same  as  liquor  sanguinis,  and. pas  corpuscles^  made  up  of 
living  or  dead  leucocytes. 


20  ESSENTIALS    OF    SURGERY. 

Name  the  varieties  of  pus. 

Laudable.  Thick  and  cream-like  ;  this  variety  comes  from 
ordinary  acute  inflammation  in  healthy  subjects. 

Sanious.  Thin,  reddish,  mixed  with  blood.  From  malignant 
disease,  chronic  ulcers,  etc. 

Ichorous.  Thin,  watery,  irritating.  From  chronic  ulcers, 
bone  disease,  etc. 

Curdy  or  cheesy.  Contains  flakes  of  degenerated  fibrin.  From 
chronic  abscesses  connected  with  bone  disease. 

Gummy.     Thick  and  ropy.     From  syphilitic  abscesses. 

Contagious  pus.     Muco  pus,  etc. 

What  becomes  of  pus  ? 

It  may  be  disintegrated  and  absorbed  ;  it  may  be  discharged  ; 
its  more  liquid  portions  may  be  absorbed,  while  the  solid  portions, 
together  with  the  affected  tissues,  undergo  fatty  disintegration 
and  remain  as  a  putty-like  mass,  this  constitutes  caseation. 

Name  the  varieties  of  suppuration. 

Circumscribed.  Diff'use.  The  diffuse  may  be  superficial  as  in 
the  cases  of  coryza  and  dysentery  ;  or  deep  as  in  cellulitis. 

What  are  the  symptoms  of  acute  inflammation  ? 

Fever,  together  with  redness,  heat,  swelling,  pain,  alteration  of 
function  and  nutrition. 

What  are  the  characteristics  of  inflammatory  redness  ? 

It  is  persistent;  if  the  capillaries  are  emptied  by  pressure  with 
the  finger  the  redness  instantly  returns  on  removal  of  the  pressure. 
The  shade  of  color  depends  upon  the  rapidity  and  freedom  of 
the  circulation ;  if  dark  or  bluish  it  denotes  obstruction  or  stasis. 
Copper-red  often  denotes  syphilitic  inflammation.  Kose-red 
streaks  along  the  course  of  the  lymph  vessels  denote  lymphan- 
gitis.    A  dusky -red  tract  in  the  course  of  a  vein  indicates  phlebitis. 

At  what  portion  of  an  inflammatory  area  is  heat  most  marked? 

At  the  focus  or  centre. 

Describe  inflammatory  swelling. 

It  is  due  to  the  increased  amount  of  blood  in  the  part,  to  pro- 
liferation, and  to  exudation.     It  is  soft  in  acute,  hard  in  chronic 


INFLAMMATION.  21 

inflammations;  is  especially  well  marked  in  loose  connective 
tissues.  Its  limitations  by  fascia  may  indicate  the  seat  of 
inflammation. 

Describe  inflammatory  pain. 

It  is  i:)ersistent^  increased  by  pressure  or  motion,  and  accom- 
panied by  the  signs  of  inflammation.  Is  mainly  due  to  mechanical 
injury  to  the  nerves  from  the  swelling.  Most  intense  in  dense 
structures.  May  be  felt  in  regions  remote  from  the  inflamed 
area  ;  instance,  the  knee  pain  of  coxalgia  or  the  shoulder  pain 
of  hepatitis. 

Describe  inflammatory  alteration  of  function. 

Secretions  are  perverted  or  abolished.  Eeflexes  become 
greatly  exaggerated ;  instance,  the  tenesmus  (straining)  of 
dysentery,  the  strangury  of  cystitis,  the  convulsions  of  teething. 
Kon-sensitive  parts  become  hyper-sensitive  ;  instance,  the  pain 
of  peritonitis  or  of  teething. 

Describe  the  constitutional  symptoms  of  inflammation. 

Fever.     May  be  sthenic  or  asthenic  in  type. 

1.  Sthenic  inflammatory  fever. 

a.  Circulatory  symptoms.  Full,  strong,  rapid  pulse,  flushed 
face,  injected  conjunctivae. 

h.  Nervous  system.  Increased  temperature,  100°  to  103^,  head- 
ache, lumbar  pains,  troubled  sleep,  special  senses  often  hyper- 
sesthetic. 

c.  Glandular  system  and  alimentary  tract.  Secretions  dimin- 
ished and  scanty  ;  dark  colored  irritating  urine  of  high  specific 
gravity.  Anorexia— heavy  white  or  yellowish  coating  on  the 
tongue.     Constipation. 

2.  Asthenic  inflammatmy  fever.  The  general  symptoms  are 
the  same  as  those  of  the  sthenic  type,  except  there  is  profound 
depression  in  place  of  over  action,  and  the  patient  shortly  falls 
into  the  typhoid,  condition.  Pulse  feeble,  rapid,  and  compres- 
sible. Temperature  fluctuating  from  99*^  or  100°  to  103°  or  even 
105.O  Mental  condition  dull  and  torpid,  or  delirious  and  busy. 
Tongue  dry,  with  brown  or  black  coat. 


22  ESSENTIALS    OF    SUKGERY. 

How  do  you  treat  inflammation  ? 

Locally  and  constitutloQally. 

Give  the  local  treatment  of  inflammation. 

'  Bemove  the  cause.  Best,  either  general  by  putting  the  patient 
to  bed,  or  local  by  the  employment  of  splints  and  bandages. 

Position.  Elevation  with  relaxation  of  all  structures  by  posi- 
tion. 

Cold,  may  be  employed  with  or  without  moisture  ;  ice-bag, 
irrigation,  rubber  tubes,  cold  compresses,  and  evaporating 
lotions.     Use  in  the  heginning  of  acute  inflammation. 

Heat,  may  be  combined  with  moisture  ;  hot  cans  or  bottles, 
poultices,  spongio  piline,  irrigation,  baths,  douches. 

Local  depletion.     Cups,  leeches,  and  scarification. 

Counter-irritation.  Tr.  iodin.,  mustard  plaster,  turpentine, 
chloroform  liniment,  actual  cautery,  seton,  issue. 

Vesication.     Fly  blister,  cantharidal  collodion. 

Pressure.  Either  direct,  or  on  the  main  bloodvessel  of  the 
part. 

What  are  the  contraindications  to  the  use  of  cold  in  inflamma- 
tion ? 

It  should  not  be  employed  where  there  is  great  impairment 
of  vitality,  either  local  or  general,  where  it  is  disagreeable  to  the 
patient,  or  after  inflammation  is  fuWj  established. 

How  does  heat  control  inflammation  ? 

It  restores  tonicity  to  the  bloodvessels,  increases  the  rapidity 
of  the  circulation,  hastens  resolution,  and  is  a  powerful  vitalizer. 

Under  what  circumstances  are  heat  and  moisture  indicated  ? 

Where  there  is  great  tension  ;  where  sloughs  or  dead  parts  are 
to  be  separated  ;  where  suppuration  is  taking  place. 

What  conditions  indicate  the  employment  of  local  depletion  ? 

A  condition  of  vascular  engorgement  so  great  that  the  vitality 
of  the  part  is  threatened  ;  instance,  scarification  in  prolapsed 
hemorrhoids  or  acute  conjunctivitis 

Describe  cupping. 

If  the  blood  is  to  be  merely  drawn  to  the  surface,  dry  cupping 


INFLAMMATION.  23 

is  employed.  This  may  be  accomplished  by  a  regular  apparatus, 
or  by  lighting  a  few  drops  of  alcohol  poured  into  a  small  cup  or 
glass,  and  suddenly  clapping  it  to  the  surface  to  be  treated.  A 
powerful  vacuum  is  created,  and  the  skin  is  drawn  far  into  the 
hollow  of  the  cup.  If  blood  is  actually  to  be  abstracted,  wet  cups 
are  used.  Incisions  are  made  through  the  skin,  and  free  bleed- 
ing is  encouraged  by  applying  cups  over  these  parts. 

Describe  leeching. 

The  Swedish  leech  is  generally  used  ;  it  draws  about  f3ss 
of  blood.  Wash  the  surface  of  the  skin  carefully,  apply  a  little 
milk  or  blood  to  it,  put  the  leech  in  a  wide-necked  bottle,  and 
press  the  mouth  of  the  bottle  against  the  surface  to  be  bled.  Let 
the  leech  drop  off,  and  check  the  bleeding  either  by  a  pledget  of 
styptic  cotton,  by  compress  and  bandage,  or  by  passing  a  hare- 
lip pin  through  the  depth  of  the  leech  bite  and  tying  around  it. 

What  parts  should  be  avoided  in  applying  leeches  ? 

Leeches  should  not  be  placed  over  loose  cellular  tissue.  In- 
stance, the  eyelids  and  the  scrotum. 

When  do  you  use  counter-irritation  ? 

As  counter-irritation  acts  by  drawing  the  blood  from  the  in- 
flamed part,  it  may  be  used  in  the  very  beginning  as  a  means  of 
aborting  inflammation.  It  may  be  employed  for  the  relief  of 
pain,  or,  as  inflammation  is  subsiding,  its  use  may  materially 
hasten  resolution. 

Describe  the  application  of  counter-irritants. 

A  mustard  plaster  must  never  be  allowed  to  blister.  Mix  one 
part  mustard,  two  parts  flour,  and  cover  with  a  thin  film  of  egg 
albumen  or  molasses.  The  more  severe  forms  of  counter-irri- 
tation, the  actual  cautery,  the  seton,  and  the  issue,  are  especially 
applicable  to  chronic  inflammation.  In  using  the  actual  cautery 
the  part  may  be  previously  anaesthetized  by  freezing.  The  seton 
is  made  by  passing  some  strands  of  silk  or  other  material  through 
a  pinched  up  fold  of  the  skin,  and  leaving  them  in  place,  slightly 
moving  them  from  day  to  day  to  keep  up  irritation.  The  issue 
is  an  ulcer  made  by  cautery  or  chemicals,  and  kept  open  by  a 
foreign  body,  such  as  a  pea  or  a  pebble. 


24  ESSENTIALS    OF    SURGERY. 

Describe  vesication. 

This  is  really  a  powerful  form  of  counter-irritation  combined 
with  depletion.  Cantharides  in  some  of  its  forms  is  generally 
used,  either  the  cerate  or  cantharidal  collodion.  After  six  hours 
apply  a  poultice  ;  small  blisters  frequently  repeated  are  termed 
fugitive  blisters. 

What  dangers  attend  the  use  of  cantharides? 

It  may  be  absorbed  and  produce  strangury,  i.  e.,  inflamma- 
tion of  the  genito-urinary  tract,  attended  with  great  pain,  and 
constant  straining  to  pass  water,  with  the  evacuation  of  a  few 
drops  at  a  time.  Treat  by  opium  and  belladonna  suppositories, 
demulcent  drinks,  warm  sitz  baths,  and  leeches.  Avoid  by  re- 
moving the  blister  after  six  hours  and  applying  a  poultice,  or  by 
incorporating  camphor  with  the  cantharidal  cerate. 

In  old  and  debilitated  persons  extensive  sloughing  may  follow 
the  use  of  blisters. 

When  is  pressure  used  ? 

Either  in  the  very  beginning,  or  after  the  inflammatory  swell- 
ing has  reached  its  height.  It  supports  the  bloodvessels,  pre- 
vents exudation,  and  hastens  resolution.  The  ordinary  or  the 
rubber  bandage  may  be  employed.  Often  the  sand  bag  or  shot 
bag  is  of  service. 

Give  the  constitutional  treatment  of  inflammation. 

1.  Bleeding  or  general  depletion.  To  be  employed  only  in  the 
strong  and  plethoric  at  the  heginning  of  an  attack^  and  where 
life  or  the  vitality  of  an  important  organ  is  threatened  by  the 
violence  of  the  congestive  symptoms.  Instance,  incipient  menin- 
gitis or  pulmonitis.  Place  the  patient  in  a  semi-recumbent  pos- 
ture^ tie  a  cord  or  bandage  about  the  middle  of  the  arm,  making 
enough  tension  completely  to  stop  the  venous  circulation,  tho- 
roughly disinfect  the  skin  in  the  region  of  incision.  Under  all 
antiseptic  precautions  divide  the  median  cephalic  vein,  and 
when  sufficient  blood  has  been  drawn  close  the  wound  with 
a  compress  of  iodoform  gauze  ;  remove  the  fillet  from  the  arm, 
apply  a  small  antiseptic  dressing,  and  put  on  a  tight  spiral  re- 
versed of  the  upper  extremity,  carrying  the  hand  in  a  sling.     In 


INFLAMMATION.  25 

case  of  brain  congestion  bleed  from  the  external  jugular.     Bleed 
till  the  pulse  becomes  soft  and  slow. 

2.  Cardiac  sedatives.  Used  where  the  pulse  is  full  and  bound- 
ing in  acute  inflammation.  Tr.  acouit.  rad.  gtt.  ij,  or  tr.  verat. 
vir.  gtt.  V,  hourly.  Ex.  gelsem.  fl.  TTLv  every  two  hours.  Care- 
fully watch  the  effect  of  cardiac  sedatives,  especially  aconite. 

3.  Diaxjhoretics  and  diuretics.  Applicable  to  nearly  all  forms 
of  inflammatory  fever.  Liq.  amnion,  acetat.  or  mist.  pot.  cit. 
f  Jss,  spirit,  seth.  nit.  f^ss  well  diluted,  or  pot.  nit.  gr.  v,  every 
two  hours.  Citrate  of  caffein  or  infusion  of  digitalis  may  also  be 
given. 

4.  Cathartics.  In  the  beginning  of  an  acute  attack  of  inflam- 
mation the  bowels  should  be  thoroughly  cleared.  This  may  be 
effected  by  blue  mass  gr.  x,  followed  in  six  hours  by  a  seidhtz 
powder,  or  calomel  gr.  ^,  sod.  bicarb,  gr.  iij,  repeat  every  hour 
till  evacuation,  or  liquorice  powder  3j.  Keep  the  bowels  regu- 
lated by  Janos  or  Carlsbad  water. 

5.  Antipyretics.  Quinine  gr.  xx,  antipyrine  gr.  xv,  antifebrine 
gr,  V.    JSTot  to  be  used  unless  the  fever  exceeds  103°. 

6.  Anodynes.  Morphia  for  acute  pain,  gr.  |  hypodermically. 
Bromide  and  caffein  for  headache.  Chloral  and  bromide  for 
restlessness. 

7.  Stimulants.  Always  in  the  asthenic  or  typhoid  form  of  sur- 
gical fever.  Where  there  are  symptoms  of  depression,  brandy, 
whiskej^  or  wine,  given  at  regular  intervals  with  the  food. 

8.  Tonics.  After  the  acute  stage  has  passed,  tr.  cinch,  comp. 
elix.  calisay.,  or  quinine. 

9.  Diet.  Water  and  cracked  ice  for  two  or  three  days  if  the 
symptoms  are  very  acute,  and  the  affection  not  liable  to  termi- 
nate in  the  typhoid  condition.  Follow  by  milk  taken  in  small 
quantities  and  at  regular  intervals.  As  the  fever  subsides  the 
diet  can  be  rapidly  increased.  For  adynamic  fever  fullest  diet 
the  patient  can  digest  from  the  first.  Milk  three  pints  daily 
with  mnlt,  oyster  juice,  raw  oysters,  peptonized  raw-meat  juice, 
liquid  pcptonoids,  beef  tea,  etc. 

What  symptoms  call  for  the  use  of  stimulants  ? 
A  weak  pulse,  particularly  if  associated  with  delirium.     The 


26  ESSENTIALS    OF    SURGERY. 

guide  as  to  the  quantity  to  be  employed  is  the  pulse;  if  it  be- 
comes slower  and  fuller  the  stimulants  are  doing  good. 

What  are  the  symptoms  of  chronic  inflammation  ? 

The  same  as  in  acute  but  less  marked ;  any  or  all  of  the 
cardinal  symptoms  may  be  so  slight  as  to  escape  notice. 

What  are  the  causes  of  chronic  inflammation  ? 

Preceding  acute  inflammation.  Long  continued  local  irrita- 
tion orfunctional  activity.     Constitutional  weakness  or  diathesis. 

What  is  the  pathology  of  chronic  inflammation  ? 

A  large  amount  of  plastic  lymph  is  effused  and  undergoes 
partial  organization,  causing  considerable  induration.  This  in- 
duration greatly  slows  the  circulation  by  compressing  the  blood- 
vessels. The  infiltrated  tissues  undergo  fatty  degeneration  and 
may  break  down  forming  cold  abscesses. 

How  do  you  treat  chronic  inflammation  ? 

1.  Local.  Bemove  cause. — May  be  sequestrum  or  foreign  body. 
Bestj  general,  in  bed  ;  local,  by  splints  and  bandages.  Local  de- 
pletion.— By  leeches  and  scarification.  Vesication.  — Small  and 
frequently  repeated  blisters.  Counter-irritation. — Actual  cauterj^, 
setons,  issues.  Alteratives. — Tr.  iodin.,  unguent,  iodin.  comp., 
unguent,  hydrarg.  cum  belladon.  Irrigation  and  jjressure. — 
Apply  a  tight  roller  bandage  and  keep  wet  by  cold  or  hot  irri- 
gation. This  is  the  most  efficient  local  treatment  of  chronic 
inflammation.     Massage — Electricity. 

2.  Constitutional. — Fresh  air,  generous  diet,  stimulants,  and 
tonics.     Mercury,  iodine  and  iodides.     Cod-liver  oil. 

When  must  mercury  be  avoided  ? 

In  strumous,  tubercular,  and  broken  down  constitutions. 

How  is  mercury  given  ? 

Hydrarg.  chlor.  mit.  gr.  I,  Dover's  powder  gr.  ij.,  give  every 
two  hours.  Mainly  used  in  head  injuries  or  inflammations,  also 
advised  in  inflammation  of  all  serous  membranes. 

What  is  meant  by  salivation  ? 
The  constitutional  effect  of  an  overdose  of  mercury.     Early 


INFLAMMATION.  27 

symptoms,  a  fodid  breath  followed  by  tenderness  of  the  gums, 
noticed  on  chewing.  Metallic  taste  in  the  mouth.  Copious 
flow  of  saliva. 

How  do  you  treat  salivation  ? 

Stop  the  mercury,  open  the  bowels,  use  a  mouth  wash  contain- 
ing tr.  myrrh,  and  pot.  chlor.  Administer  belladonna  or  atropia 
in  fairly  full  doses. 


Abscess. 

What  is  an  abscess  ? 

A  collection  of  pus  surrounded  by  a  wall  of  lymph.  An  ab- 
scess is  a  hollow  ulcer. 

Describe  the  formation  of  abscess. 

From  excessive  or  continued  irritation  there  is  an  exudation 
so  copious  that  not  only  are  the  lymph  channels  blocked  but 
there  is  absolute  blood  stasis  and  coagulation;  the  central 
portion  of  the  exudation  and  the  involved  tissues  perish  forming 
pus ;  the  peripheral  portions,  however,  are  not  absolutely  cut 
oft'  from  nutrient  blood,  they  undergo  organization  and  form 
around  the  central  part  a  bank  of  organized  lymph  or  granu- 
lation tissue  ;  this  serves  a  double  purpose ;  to  prevent  the 
extension  of  the  suppurative  process,  and  to  provide  for  the 
healing  of  the  abscess  when  the  pus  is  evacuated.  The  direct 
cause  of  the  pus  formation  is  the  presence  of  micro-organisms  in 
the  exudate. 

What  symptoms  denote  the  formation  of  an  abscess  ? 

Throbbing  pain.  Increase  in  swelling.  Color  darker,  surface 
at  times  glazed.  Tendency  to  point.  Fluctuation  elicited  by 
palpation,  percussion,  and  pressure.     Bigors  and  fever. 

In  what  direction  does  an  abscess  point  ? 

In  the  direction  of  least  resistance.  This  is  usually,  but  not 
always  towards  the  surface. 

What  local  symptoms  point  to  deep  suppuration  ? 

Pain  and  oedema. 


28  ESSENTIALS    OF    SURGERY. 

How  do  you  treat  an  acute  atscess? 

Endeavor  to  abort  by  the  use  of  heat  (110°),  cold,  local  de- 
pletion or  blisters.  If  these  fail,  relieve  tension  and  hasten  sup- 
purailon  by  poulticing.  When  fluctuation  is  detected,  opeyi 
under  antiseptic  precautions,  wash  out  the  cavity  with  bichlo- 
ride solution  1 :  1000,  drain,  and  apply  a  Lister  dressing. 

How  do  you  open  an  abscess  ? 

If  superficial,  with  one  quick  cut.  If  deep,  make  an  incision 
with  the  scalpel  to  the  deep  fascia,  through  this  a  director  is 
passed  and  forced  on  till  it  enters  the  abscess  cavity.  A  pair 
of  dressing  forceps,  closed,  is  carried  along  the  director  ;  by  open- 
ing these  and  drawing  out  forcibly  a  free  opening  is  made  without 
endangering  bloodvessels.  In  evacuating  pus,  bear  in  mind  that 
any  violence,  which  breaks  down  the  organized  walls  of  lymph 
or  granulation,  retards  healing,  hence  if  pus  is  squeezed  out  it 
must  be  by  means  of  gentle  pressure  made  with  pledgets  of 
cotton. 

In  what  regions  must  abscesses  be  opened  before  fluctuation  is 
detected  ? 
1.  Ischiorectal,  to  prevent  pointing  into  the  rectum  (path  of 
least  resistance).  2.  Perineal.  3.  Palmar.  4.  Tonsillar.  5. 
Postpharyngeal.  6.  Any  abscess  near  important  bloodvessels 
or  beneath  deep  fasciae. 

What  circumstances  may  retard  the  healing  of  abscess  after 
incision  ? 

1.  Want  of  free  drainage.  To  remedy,  enlarge  the  opening, 
or  make  another  in  a  more  dependent  position,  or  insert  drain- 
age tube. 

2.  Imperfect  apposition  of  the  granulation  walls,  hemorrhage,  or 
hreak  in  the  limiting  walls  allowing  an  infiltration  of  pus  into  the 
surrounding  tissue.     Treat  by  compress  and  bandage. 

3.  Indolent  granulations  or  constitutional  weakness.  Treat 
locally  by  stimulating  applications.  Cu.  sulph.  or  argent,  nit. 
gr.  iv  to  aq.  f  Jj,  iodoform  ;  the  constitutional  condition  must  be 
remedied  by  tonics  and  stimulants. 


INFLAMMATION.  29 

How  does  a  chronic  atscess  differ  from  an  acute  one  ? 

The  course  is  slow,  the  signs  and  symptoms  are  slight  or  want- 
ing. The  tendency  to  point  is  not  marked,  pus  accumulating  at 
times  to  an  extraordinary  extent  before  the  skin  shows  signs  of 
yielding.  The  pus  corpuscles  are  broken  up  and  there  are  few  or 
no  micro-organisms  to  be  found  on  microscopic  examination.  The 
granulation  wall  is  very  thick,  partially  organized  into  connec- 
tive tissue,  and  showing  little  tendency  toward  the  production 
of  healthy  granulation.  The  condition  is  one  of  passive  conges- 
tion rather  than  active  hypersemia,  hence  the  name  congestive 
abscess ;  called  also  cold  abscess  from  the  slight  development  of 
inflammatory  heat. 

What  are  the  constitutional  symptoms  of  chronic  abscess  ? 

May  be  slight  or  wanting  till  the  abscess  bursts  or  is  opened, 
when  hectic  quickly  develops  ;  by  this  is  meant  a  daily  rise  in 
temperature,  often  preceded  by  rigors,  and  followed,  after  some 
hours,  by  profuse  sweating  with  subsidence  of  fever.  Emaciation 
is  continuous  and  rapid. 

How  do  you  treat  a  chronic  abscess  ? 

Generous  diet,  stimulants,  tonics,  iodide  of  iron,  and  cod-liver 
oil.  Unless  the  abscess  is  stationary,  and  giving  no  trouble 
either  directly  or  indirectly,  open  at^  once  under  strictest  anti- 
septic precautions.  Aspiration  followed  by  pressure  may  succeed 
when  there  is  no  bone  involvement.  Usually  incision  will  be 
necessary  ;  the  cut  must  be  as  far  removed  from  sources  of  con- 
tagion as  possible  (hence  open  psoas  abscess  ahove  Poupart's  liga- 
ment), and  planned  to  thoroughly  drain  the  cavity.  Irrigate 
daily  with  5  per  cent,  sterilized  salt  solution,  1  per  cent,  carbolic, 
or  1  :  6000  bichloride.  Apply  each  time  a  complete  antiseptic 
dressing,  providing  cushions  of  jute,  oakum,  sea  moss,  or  cotton 
to  receive  and  absorb  the  discharge. 

What  are  the  chief  characteristics  of  tubercular  abscess  ? 

They  are  chronic,  have  a  tendency  to  caseation  and  long-con- 
tinued discharge,  and  affect  mainly  bones,  lympjh  glands^  and  lungs. 


30  ESSENTIALS    OF    SURGERY. 

How  do  you  treat  tubercular  abscess  ? 

Thoroughly  remove  the  affected  area  by  means  of  the  knife  or 
curette  under  antiseptic  precautions. 

What  is  a  residual  abscess  ? 

An  abscess  which  appears  at  or  about  the  seat  of  a  former 
suppuration  ;  commonly  due  to  caseous  masses. 

What  is  a  sinus  ? 

A  suppurating  canal,  left  by  an  imperfectly  healed  wound  or 
abscess. 

What  is  a  fistula? 

A  communication  between  two  mucous  cavities,  or  between  a 
mucous  cavity  and  the  external  air,  by  means  of  a  suppurating 
canal. 

How  do  you  treat  sinus  and  fistula? 

Remove  all  irritating  causes  and  bring  the  walls  together  by- 
pressure,  employing  stimulating  injections  (silver,  copper,  zinc) ; 
or  freely  lay  open,  and  by  gentle  packing  with  iodoform  gauze, 
cause  healing  from  the  bottom. 

How  do  you  diagnose  abscess  from  aneurism  ? 

Should  abscess  occur  in  the  immediate  neighborhood  of  a 
large  vessel  the  history  will  be  one  of  previous  inflammation  ; 
the  pulsation  of  abscess  is  a  simple  lifting  impulse,  not  an  expansive 
throb  ;  the  abscess  may  be  absolutely  isolated  from  the  artery  by 
manipulation  ;  pressure  on  the  distal  side  does  not  increase  the 
tension  of  abscess,  nor  does  pressure  on  the  proximal  side  di- 
minish it.  Abscess  gives  no  thrill,  no  bruit ;  finally,  if  there  be 
the  chance  of  a  doubt,  the  exploring  needle  gives  pus  from  the 
abscess. 

How  do  you  distinguish  encephaloid  disease  from  abscess? 

In  soft  cancer  the  course  is  chronic,  and  at  first  painless ;  it 
presents  multiple  eminences,  has  large  purple  veins  coursing 
over  it,  and  is  elastic  rather  than  fluctuating. 


INFLAMMATION.  31 

XTlceration. 

What  is  ulceration  ? 

The  molecular  death  of  tissues,  leaving  a  solution  of  continuity, 
and  accompanied  by  a  discharge. 

What  are  the  causes  of  ulceration  ? 

1.  Predisposing,  quantity  and  quality  of  the  blood,  together  with 
the  freedom  and  rapidity  of  the  circulation. 

2.  Exciting,  irritation,  physical  or  chemical. 

What  is  the  pathology  of  ulceration  ? 

As  for  abscess ;  from  over-crowding,  the  tissues  and  effused 
matter  about  the  focus  of  inflammation  perish,  the  peripheral 
areas  become  vascularized,  and  are  converted  to  granulations. 

What  is  a  granulation  ? 

A  capillary  loop  about  which  are  clustered  leucocytes,  held 
together  by  a  slight  amount  of  intercellular  material. 

Describe  healthy  granulations. 

Cherry-red,  non-sensitive,  elastic,  and  discharging  laudable 
pus. 

By  what  processes  is  ulceration  healed? 

By  granulation  and  cicatrization.  While  the  dead  central 
parts  of  the  ulcer  come  away  as  a  thin  discharge  called  ichor, 
the  exudation  beneath  and  around  is  becoming  vascularized, 
capillary  loops  shoot  out  toward  the  surface  (the  direction 
of  least  resistance)  ;  about  each  loop  clings  a  cluster  of  living 
leucocytes,  and  a  surface  of  healthy  granulation  is  established, 
discharging  laudable  pus.  Cicatrization  now  begins,  the  sur- 
rounding skin  sinks  to  the  level  of  the  granulations,  and  its  epi- 
thelial cells  undergo  segmentation  and  grow  as  a  ring  about  the 
periphery  toward  the  centre  of  the  ulcer  ;  this  skinning  over  is 
denoted  by  a  blue  film,  and  while  it  is  extending  the  ulcer  is 
contracting,  from  conversion  of  leucocyte  to  fibrous  tissue  ;  this 
contraction  goes  on  long  after  the  ulcer  is  entirely  healed,  and 
may  cause  great  deformity.     The  process  of  skinning  and  con- 


82  ESSENTIALS    OF    SURGERY. 

Describe  a  cicatrix. 

At  first  blue,  it  finally  becomes  white,  the  progressive  contrac- 
tion of  the  connective  tissue  squeezing  all  the  blood  from  the 
part.  A  cicatrix  has  neither  nerves,  glands,  lymphatics,  nor 
hair  ;  it  readily  ulcerates,  and  is  slow  in  healing. 

What  is  an  ulcer  ? 
A  surface  of  granulations. 

Name  the  varieties  of  ulcers. 

1.  Local. 

a.  Simple  healthy  or  healing. 
h.  Complicated  or  spreading. 

2.  Constitutional,  strumous,  syphilitic. 

Of  the  complicated  or  spreading  we  have  the  fungous,  the 
oedematoixs,  the  inflamed,  the  sloughing,  the  phagedenic,  the 
indolent  ulcers. 

Describe  a  simple  or  healthy  ulcer. 

Granulations,  healthy,  cherry-red,  small,  uniform,  not  painful. 
Discharge,  laudable  pus  in  small  quantity  ;  if  the  ulcer  has  been 
treated  antiseptically  the  discharge  is  serum.  Shape,  oval, 
regular.  Edges,  gently  sloping,  moderately  indurated,  showing 
the  blue  line  of  beginning  skinning.  Surrounding  skin  soft  and 
flexible. 

Give  the  treatment  of  simple  ulcer. 

In  the  forming  stage,  abort  or  limit  by  rest,  elevation,  local  de- 
pletion, and  cold  ;  at  the  same  time  treating  the  rather  high 
constitutional  symptoms  by  withholding  food,  giving  abundance 
of  water,  iced  drinks,  or  cracked  ice,  opening  the  bowels,  and, 
if  necessary,  administering  morphia  hypodermically  to  control 
the  pain. 

When  disintegration  is  evident  hasten  the  separation  of  the 
dead  from  the  living  tissues  by  warm  antiseptic  poultices 
(sponges,  lint,  or  gauze  soaked  in  weak  bichloride  solution  1:6000, 
and  covered  in  by  waxed  paper  and  a  bandage).  Milk  diet. 
When  the  dead  part  is  separated  leaving  a  surface  of  healthy 
granulations,  cleanse  with  sterihzed  salt  solution  5  per  cent. ,  or 


INFLAMMATION".         '  33 

very  weak  antiseptic  lotions,  bichloride  1 :  10,000.  Cover  with 
protective  or  gutta-percha  tissue,  and  apply  a  light  antiseptic 
dressing,  finishing  with  moderately  firm  pressure  by  a  roller 
bandage.  Full  diet.  A  healthy  ulcer  heals  kindly  under  nearly 
any  dressing. 

Describe  the  inflamed  ulcer. 

A  simple  ulcer  may  become  converted  to  an  inflamed  ulcer  by 
any  of  the  local  or  constitutional  causes  which  give  rise  to  in- 
flammation. Instance,  debauch,  injury,  etc.  Granulations^  at 
first  bright  red,  become  dusky,  finally  break  down  forming  a 
gray,  ragged,  sloughing  surface.  Discharge^  very  profuse,  con- 
sists of  pus  and  the  debris  of  broken  down  tissue.  Edges,  irregu- 
lar, deep,  sharply  cut,  indurated.  Surrounding  skin,  red  and 
oedematous.  Pain  and  tenderness  acute.  Constitutional  symp- 
toms well  marked. 

Give  the  treatment  of  inflamed  ulcer. 

A  saline  cathartic  in  the  beginning  of  the  attack.  Rochelle 
salts  5j.  Rest  in  bed  with  elevation  of  the  part.  Local  deple- 
tion by  leeches,  or  incisions  into  the  edge  of  the  ulcer.  Hot 
antiseptic  poultices.     Low  diet,  opium  to  relieve  pain. 

Describe  the  sloughing  ulcer. 

Yery  commonly  associated  with  venereal  disease.  This  is 
but  an  aggravated  inflamed  ulcer,  and  is  characterized  by  the 
same  peculiarities,  with  the  addition  that  there  is  a  rapid  spread- 
ing attended  by  destruction  oi  visible  portions  of  the  tissues  which 
are  thrown  ofi*  as  offensive  gray  sloughs.  All  symptoms,  both 
local  and  general,  are  aggravated. 

How  do  you  treat  sloughing  ulcers  ? 

Treatment  on  the  same  lines  as  for  inflamed.  Constitutional 
condition  must  receive  particular  attention,  as  all  sloughing 
processes  tend  rapidly  towards  exhaustion.  Charcoal  or  anti- 
septic poultices  till  sloughs  come  away. 

Describe  the  phagedenic  ulcer. 

This  form  is  an  aggravated  sloughing  ulcer.     Found  only  in 
venereal  disease  or  in  patients  with  profoundly  depressed  con- 
3 


34  ESSENTIALS    OF    SURGERY. 

stitution.  The  granulations  are  absent,  being  replaced  by  gray 
sloughs  ;  the  discharge  is  ichorous,  containing  shreds  of  dead 
tissue  ;  the  edges  are  ragged,  dusky  red,  and  extensively  under- 
mined ;  the  surrounding  skin  (edematous,  red.  The  extension  is 
very  rapid,  may  destroy  an  entire  organ  (the  penis),  and  is  at- 
tended by  severe  constitutional  symptoms  of  the  adynamic  type. 

Give  the  treatment  of  phagedenic  ulcer. 

Clear  the  bowels.  Eich  nourishing  diet,  stimulants,  tonics, 
opium.  Continuous  warm  baths  during  the  day,  with  iodoform 
dressing  at  night.  Or  the  ulcer  may  be  treated  by  charcoal 
poultices  and  antiseptic  washings  till  sloughs  are  separated. 

Describe  the  serpiginous  ulcer. 

This  is  really  a  phagedenic  ulcer.  Its  course  is  slow  but  per- 
sistent ;  it  may  produce  most  extensive  destruction  of  tissue. 

Treatment.  Constitutionally,  supporting  ;  locally,  actual  cau- 
tery, or  as  for  phagedenic  ulcer. 

What  is  an  irritable  ulcer  ? 

An  ulcer  which  presents  the  features  of  an  inflamed  ulcer,  to- 
gether with  great  pain,  out  of  all  proportion  to  its  apparent 
cause.  This  pain  is  probably  due  to  the  stretching  of  small  nerve 
branches. 

Treatment,  Subcutaneous  section  of  the  nerve  branch  sup- 
plying the  ulcerating  area,  or  applications  of  chloral  gr.  xx.,  or 
argent,  nit.  gr.  xx.  to  the  ounce  of  water. 

What  are  fungous  and  oedematous  ulcers? 

In  the  fungous  ulcer  the  granulations  grow  above  the  level  of 
the  surrounding  skin,  and  may  spread  out  as  a  cauliflower  or 
mushroom-like  growth  ;  they  bleed  readily.  Cause^  obstruction 
to  venous  return  from  undue  contraction  of  surrounding  tissues. 

The  (Edematous  ulcer  is  characterized  by  large,  pale,  flabby, 
-vnter}'  granulations  which  have  a  tendency  to  become  fungous. 
Cause,  venous  obstruction  combined  with  struma  or  systemic 
depression. 

How  do  you  treat  fungous  and  oedematous  ulcers  ? 

Astringent  applications.     Powdered  alum,  glycerole  of  tannin, 


INFLAMMATION.  35 

followed  hy  compression  applied  by  means  of  imbricated  adli'esive 
straps  and  a  tight  roller  bandage. 

Excision.  If  these  means  fail,  or  if  the  granulations  have 
assumed  a  mushroom-like  growth,  shave  off  level  with  the  sur- 
face, dust  with  iodoform,  and  apply  an  antiseptic  dressing,  with 
a  tight  roller  bandage  over  the  whole. 

Describe  the  indolent,  callous,  or  chronic  ulcer. 

Granulations.  Never  healthy,  usually  small,  scanty,  and 
brickdust-red  ;  frequently  fungous  or  oedematous. 

Discharge.     Ichorous  or  sanious  pus. 

Edges.  Everted  or  inverted,  irregular,  never  gently  sloping. 
Blue  nne  of  skinning  absent. 

Surrounding  skin.  Discolored,  often  eczematous  and  densely 
indurated. 

Occurs.  After  middle  age,  and  in  those  whose  occupation 
requires  long  standing. 

Favorite  seat.  The  outer  surface  of  the  lower  third  of  the  leg, 
because:  1.  It  is  an  exposed  portion.  2.  There  is  little  cellular 
tissue  separating  skin  from  bone.  3.  Its  dependent  position 
favors  passive  congestion  and  thrombosis. 

Course.     Exceedingly  slow,  may  last  many  years. 

Constitutional  symxjtoms.     None. 

The  eczematous  and  varicose  ulcers  are  simply  chronic  ulcers 
with  marked  development  of  the  affections  from  which  they 
take  their  names. 

What  prevents  chronic  ulcers  from  healing? 

From  long  congestion  the  bank  of  lymph  becomes  redundant, 
and  is,  in  part,  converted  to  imperfect  fibrous  tissue,  which,  by 
pressure  upon  the  vessels,  blocks  the  circulation. 

How  do  you  treat  chronic  ulcers  ? 

Cause  the  absorption  of  the  obstructing  bank  of  lympjh.  Healing 
granulations  will  then  appear.  This  is  accomplished  by  heat, 
moisture,  and  pressure. 

Treatment.  Soak  the  ulcer  for  two  hours  at  night  in  warm  4 
per  cent,  boracic  acid  solution,  followed  by  a  thick  poultice 
(boracic  acid  solution  and  ground  flaxseed,  the  surface  being 


36  ESSENTIALS    OF    SURGERY. 

coated  with  boracic  ointment),  well  protected  by  oiled  silk,  or 
waxed  paper,  so  that  it  may  not  cake  before  being  removed.  In 
the  morning,  substitute  for  the  poultice  strips  of  lint  wet  in 
boracic  lotion,  and  imbricated  over  the  affected  region  ;  cover 
these  strips  with  waxed  paper,  and  apply  very  carefully  over 
the  whole  a  roller  bandage,  taking  in  the  foot  and  going  as  high 
as  the  knee  :  at  night  remove  the  dressing  and  soak  again.  Con- 
tinue this  treatment  for  three  or  four  days,  or  until  the  bank  of 
induration  is  softened,  then  strap.  Use  adhesive  plasters  cut  in 
strips  one  inch  wide,  and  long  enough  to  extend  nearly  around  the 
limb.  After  elevating  the  leg  and  allowing  the  blood  to  drain 
out,  begin  the  dressing  by  applying  the  first  strap  two  inches 
below  the  lower  border  of  the  ulcer,  making  firm  pressure  as  it 
is  carried  around  the  leg  or  foot ;  the  next  strap  is  applied  nearer 
the  ulcer,  overlapping  the  first  for  two-thirds  of  its  width ;  so 
continue  till  the  ulcer  is  reached,  when  the  straps  must  overlap 
as  before,  but  in  applying  them,  first  fasten  one  end,  then  press 
the  edges  of  the  ulcer  together,  diminishing  its  size  as  much  as 
possible,  and  secure  it  in  this  position  by  continuing  the  strap 
firmly  across  it  and  around  the  limb.  The  straps  must  entirely 
cover  in  the  ulcer  and  an  area  two  inches  above  and  below. 
Over  the  straps  apply  a  layer  of  lint,  and  cover  in  the  whole  by 
a  closely  fitting  roller  bandage.  The  dressing  is  removed  and 
reapplied  as  required  by  the  amount  of  discharge.  If  this 
method  cannot  be  carried  out,  apply  a  Martin''s  riibher  bandage 
directl}^  to  the  skin  ;  removing  at  night ;  wash  night  and  morn- 
ing in  boracic  lotion. 

A  blister  applied  to  the  entire  ulcer  and  surrounding  skin  may 
cause  the  induration  to  disappear.  Incisions,  or  shaving  off  of  the 
induration  may  be  required. 

What  are  the  characteristics  of  strumous  ulcers? 

Favorite  seats  neclc  and  groin.  Chronic,  painless,  discharge  a 
thick  oily  pus,  granulations  oedematous,  skin  extensively  un- 
dermined, and  overhanging  the  ulcer  in  the  form  of  loose  blue 
flaps. 


INFLAMMATION.  37 

What  ulcers  are  mostly  found  on  the  leg  ? 

Yaricose,  traumatic,  and  syphilitic.  A  non-traumatic  ulcer 
of  the  up2)er  third  of  the  leg  is  mostly  syphilitic. 

What  ulcers  chiefly  affect  the  face  ? 

Kodent  ulcers,  and  those  due  to  lupus,  syphilis,  or  epithelioma. 
The  rodent  vJcer  is  distinguished  from  the  epitheliomatous  from  the 
fact  that  it  does  not  involve  lymphatic  glands,  nor  induce  secon- 
dary deposits  ;  its  course  is  very  slow  ;  its  base  is  smooth  and 
glossy,  with  little  or  no  discharge  ;  its  edges  moderately  indu- 
rated, smooth,  round,  and  rolled  over. 

Describe  skin  grafting^. 

By  skin  grafting  is  meant  the  placing  on  granulating  sur- 
faces of  healthy  epidermis  for  the  purpose  of  hastening  cicatri- 
zation and  preventing  subsequent  contractions.  It  il  chiefly 
applicable  where  the  granulating  surface  is  large,  or  conspicu- 
ously placed,  or  slow  in  healing.  The  granulations  must  be 
healthy,  discharging  very  slightly,  and  preferably  aseptic.  This 
may  be  accomplished  by  washing  with  weak  bichloride  solutions 
and  dressing  antiseptically  for  several  days  before  the  operation. 
The  area  from  which  the  grafts  are  taken  should  be  thoroughly 
washed  with  soap,  water,  and  bichloride,  1 :  1000,  followed  by  5 
per  cent,  sterilized  salt  solution  (sodium  chloride  5  parts,  water 
95  parts,  boil  for  one  hour).  By  means  of  a  scalpel,  scissors,  or 
a  razor,  small  or  large  pieces  of  cuticle,  including  the  rete  mu- 
cosum,  but  not  the  corium,  are  removed,  and  placed,  fresh  sur- 
face down,  on  the  granulations,  from  which  all  antiseptics  have 
previously  been  washed  by  liberal  salt  solution  irrigations. 

Apply  protective  wet  in  salt  solution,  and  either  a  sterile,  or 
an  antiseptic  dressing,  covering  in  the  whole  with  a  tight  roller 
bandage.  By  this  method  strips  of  skin,  i  in.  by  2  inf,  may  be 
transplanted  and  retain  their  vitality.  The  grafts  should  be 
taken  from  young  healthy  persons. 


38  ESSENTIALS    OF    SURGERY. 


Mortification. 

What  is  mortification  or  gangrene  ? 

Death  in  mass. 

What  is  a  slough  or  sphacelus  ? 

That  portion  of  tissue  affected  by  mortification. 

What  are  the  causes  of  gangrene  ? 

1.  Direct  violence  from  physical  or  chemical  agencies. 

2.  Deficient  blood  supply  from  inflammatory  engorgement,  weak 
circulation,  diseased  vessels,  embolus,  or  thrombus. 

Name  the  two  commonest  forms  of  gangrene. 
1.  Acute  or  moist.     2.  Chronic  or  dry. 

What  structures  resist  gangrene  ? 

Arteries  (hence  thrombi  form  before  their  walls  are  disinte- 
grated, and  bleeding  is  prevented),  nerves,  tendons,  and  bones. 

How  is  gangrene  limited  ? 

By  a  reactive  inflammation.  A  wall  of  granulation  is  thrown 
out,  at  the  expense  of  the  healthy  tissues,  by  which  the  slough  is 
separated  from  the  living  parts. 

What  first  indicates  the  limit  of  gangrenous  processes  ? 

The  line  of  demarcation.  A  red  line  due  to  capillary  conges- 
tion, indicating  the  beginning  of  inflammatory  reaction. 

What  follows  the  line  of  demarcation  ? 

The  line  of  separation.     A  line  of  ulceration  or  granulation. 

What  are  the  general  indications  in  the  treatment  of  all  gan- 
grenous processes  ? 

Keep  the  dead  or  dying  part  thoroughly  aseptic.  Cleanse,  dis- 
infect, and  wrap  in  thick  layers  of  antiseptic  wool,  cotton,  or 
gauze.  Carefully  guard  against  the  invariable  tendency  to  ady- 
namia. 


INFLAMMATION.  39 

What  are  the  symptoms  of  acute  mortification  ? 

Synonym  :  Local  traumatic  gangrene. 

Usually  acute  inflammatory  symptoms  with  evidence  of  great 
local  congestion,  and  intense  burning  pain.  Tlie  pain  ceases, 
there  is  loss  of  sensation,  of  power  to  move  the  part.  The  temper- 
ature falls,  and  pulsation  of  the  arteries  cannot  be  detected.  The 
color,  at  first  dusky-red,  turns  to  blue,  to  purple,  to  dirty  brown, 
or  black.  Blebs  form,  the  course  of  the  superficial  vessel  is 
marked  by  lines  of  dark  discoloration.  Even  yet  vitality  may  be 
restored.  If,  however,  the  cuticle  separates  from  the  derm  and 
can  be  rubbed  off  by  light  pressure,  if  there  is  crackling,  emphy- 
sema, and  foul  odor,  death  is  absolute. 

The  constitutional  symptoms  are  those  of  inflammatory  fever, 
but  of  an  adynamic  or  typhoid  type.  Kapid,  feeble  pulse,  low 
delirium,  etc. 

How  do  you  treat  acute  mortification  ? 

Preventive.  Believe  tension.  Eemove  tight  bandages.  Evac- 
uate retained  discharges.  Freely  incise  inflammatory  congestions. 
Massage.     Bender  the  part  aseptic  ;  wrap  in  antiseptic  wool. 

If  the  slough  is  thoroughly  established,  and  is  putrid,  char- 
coal poultices  or  wet  bichloride  dressings  may  be  used  ;  other 
wise,  dry  antiseptic  dressings  are  indicated. 

Amputate  when  the  line  of  demarcation  is  formed.  (In  the  hand 
and  foot  spontaneous  amputation  generally  gives  a  better  stump 
than  the  surgeon's  knife.) 

Constitutional  treatment :  Very  free  stimulation,  full  nourishing 
diet,  quinine,  and  opium. 

What  is  spreading  traumatic  gangrene  ? 

An  acute,  rapidly  spreading,  moist  gangrene,  dependent  on  a 
specific  micro-organism.  It  appears  shortly  after  severe  trau- 
matism, and  before  the  line  of  separation  can  form,  extensively 
invades  the  tissues,  and  causes  death  from  exhaustion  or  septic 
poisoning.  All  local  inflammatory  symptoms  may  be  absent ; 
swelling,  discoloration,  and  loss  of  temperature  circulation  and 
sensation,  denoting  the  extension  of  the  process.  In  other  cases, 
an  inflammatory  redness  and  induration  precede  the  gangrene. 
The  constitutional  symptoms  are  profoundly  adynamic. 


40  ESSENTIALS    OF    SURGERY. 

How  do  you  treat  spreading  traumatic  gangrene  ? 

Immediate  amputation  through  healthy  tissue. 

What  is  hospital  gangrene  ? 

An  epidemic,  contagious,  gangrenous  process,  dependent  upon 
the  presence  of  micro-organisms,  which  destroj^s  granulations, 
attacks  the  tissues  lying  about  and  beneath  them,  and  rapidly 
produces  extensive  sloughs. 

Give  the  symptoms  of  hospital  gangrene. 

As  for  acute  mortification.  The  surface  of  a  wound,  or  its 
margins,  are  rapidly  converted  into  an  extensive  slough,  there  is 
surrounding  oedema  and  congestion,  the  discharge  is  foul,  the 
process  rapidly  extends. 

The  constitutional  symptoms  are  adynamic  ;  high  temperature 
at  first,  with  weak,  quick  irregular  pulse,  wet  surface,  and,  fre- 
quently, muttering  delirium. 

What  circumstances  predispose  to  attacks  of  hospital  gan- 
grene ? 

Over-crowding^  deficient  ventilation,  want  of  proper  nourish- 
ment, or  any  depressing  cause. 

How  do  you  treat  hospital  gangrene  ? 

Isolate  the  patient.  Break  up  the  sloughs  by  thrusting  closed 
dressing  forceps  through  them,  and  withdrawing  the  forceps 
opened.  In  these  openings  make  a  thorough  application  of  pure 
bromine,  nitric  acid,  or  other  escharotic.  Dress  with  anti- 
septic charcoal  poultice,  and  subsequently  observe  the  most  rigid 
asepsis  in  regard  to  wound  treatment. 

Constitutionally  give  stimulants^  free  diet,  quinine,  iron,  and 
opium. 

What  is  cancrum  oris  ? 

Synonym.     Gangrenous  stomatitis. 

It  is  a  gangrenous  ulcer  of  the  cheek  or  gums,  occurring  in 
poorly  nourished  children.  It  is  frequently  developed  after  an 
attack  of  measles,  scarlet  fever,  or  typhoid  fever.  It  usually 
appears  opposite  a  rough  or  decayed  tooth,  which  has  caused. 
an  abrasion.    It  is  seen  in  the  mouth  as  an  offensive,  sloughing, 


INFLAMMATION.  41 

punched  out  ulcer ;  on  the  external  surface  of  the  cheek  as  a 
glazed,  dusky  red,  indurated  spot,  which  is  shortly  converted  into 
a  black  slough,  causing  perforation,  and  extensive  destruction 
of  tissue.  The  constitutional  symptoms  are  those  characteristic 
of  all  gangrenous  processes. 

How  do  you  treat  cancrum  oris  ? 

Thoroughly  cauterize  ^\\ih.  nitric  acid.  Wash  at  intervals  with 
boracic  acid  lotion,  or  tr.  myrrh.  Give  internally  stimulants, 
rich  milk  in  abundance,  malt,  iron,  and  quinine. 

What  is  noma  pudendi? 

A  gangrenous  process  similar  to  cancrum  oris,  attacking  the 
genitals  of  female  children.     Treatr^ient.    As  for  cancrum  oris. 

What  is  a  bed  sore  ? 

A  sloughing  ulcer,  due  to  pressure,  appearing  on  the  bony 
prominences  of  the  weak  and  badly  nourished. 

How  do  you  treat  bed  sores  ? 

Clear  away  the  slough  by  charcoal  poultices,  wash  and  dress 
antiseptically,  relieve  the  part  from  pressure  by  pads,  pillows, 
or  air  cushions. 

Describe  a  furuncle. 

Synonym,     Boil. 

Definition.  A  circumscribed  inflammation  of  the  skin  and 
subcutaneous  tissue,  terminating  in  suppuration,  and  the  forma- 
tion of  a  central  slough  or  core. 

Occurs.     In  crops,  on  the  neck,  nates,  and  back  of  the  young. 

Causes.  Systemic  depression,  and  the  rubbing  into  the  ducts 
or  hair  follicles  of  the  skin  of  a  micro-organism. 

Begins  as  a  red  pimple,  usually  with  a  hair  in  the  centre,  in- 
creases rapidly  in  size,  causing  a  purple-red,  very  painful 
swelling  which  may  undergo  resolution  (blind  boil),  or  open,  dis- 
charging the  central  core. 

Treatment.  1.  Pull  out  the  central  hair,  wash  thoroughly 
with  bichloride,  apply  50  per  cent,  ichthyol  ointment.  2.  Inject 
with  Tn.v.  of  a  10  per  cent,  solution  of  carbolic  acid.  3.  If  in- 
flammatory symptoms  increase  in  severity,  apply  spongio  piline 


42  ESSENTIALS    OF    SURGERY. 

dipped  in  hot  boracic  or  carbolic  *acid  lotion.  4,  When  fluctua- 
tion is  evident,  incise,  syringe  the  cavity  with  antiseptic  solution, 
and  apply  an  antiseptic  dressing,  making  firm  pressure. 

What  is  a  carbuncle  ? 

An  inflammation  of  the  skin  and  subcutaneous  tissues,  in- 
volving a  much  larger  surface  than  furuncle,  and  attended  by 
the  formation  of  sloughs  of  considerable  size. 

It  differs  from  boil  in  being  much  larger,  flattened  instead  of 
conical,  and  accompanied  by  great  surrounding  oedema.  The 
skin  gives  way  in  several  places,  sloughs  of  some  size  are  dis- 
charged.    Constitutional  symptoms  are  severe. 

Occurs  in  the  aged  and  debilitated. 

Cause.     The  rubbing  in,  by  friction,  of  a  micro-organism. 

Seats.  Neck,  back,  nates.  "When  occurring  on  the  face  or 
head  it  is  exceedingly  fatal. 

Give  the  symptoms  of  carbuncle. 

A  hard,  brawny,  flattened,  dusky-red  area  of  induration,  cir- 
cular in  shape,  and  riddled  with  apertures,  through  which  a 
gray  slough  can  be  seen.  The  constitutional  symptoms  are 
severe  and  of  an  adynamic  type. 

Give  the  treatment  of  carbuncle. 

The  constitutional  treatment  should  be  conducted  on  the  plan 
indicated  for  all  gangrenous  processes.  Stimulants,  full  diet, 
iron,  quinine,  and  opium  may  be  given.  Locally,  the  affection 
may  be  treated  by — 

1.  Tight  concentric  strapping,  leaving  a  central  aperture  for 
the  escape  of  sloughs. 

2.  Hot  fomentations  or  poultices,  the  moisture  being  supplied 
by  boracic  or  carbolic  acid  solution.  Heat  and  moisture  may 
be  combined  with  strapping. 

3.  Injections  through  the  inflamed  area,  and  about  its  periph- 
ery, of  carbolic  acid  (5  or  10  per  cent,  in  glycerine) ;  as  much 
as  a  half  drachm  may  be  used. 

4.  Crucial  incision,  and  removal  by  curetting  of  all  the  involved 
cellular  tissue.  The  operation  must  be  done  antiseptically. 
Pack  the  wound  with  iodoform  gauze,  and  apply  a  thick  antisep- 
tic dressing. 


INFLAMMATIOX.  43 

What  is  the  usual  cause  of  dry  gangrene? 

Synonym  :  Senile  or  chronic  gangrene. 

Cause.     Arterial  obstruction  from  atheroma  and  thrombosis. 

What  are  the  premonitory  symptoms  of  senile  gangrene  ? 

The  limb  feels  cold  and  nurnh ;  tingles  and  is  subject  to  shooting 
and  violent  pains  ;  steady  deterioration  in  health. 

What  symptoms  denote  the  onset  of  the  disease  ? 

The  appearance  of  a  black  spot,  usually  to  the  inner  side  of 
the  great  toe,  surrounded  by  a  dusky-red  areola,  and  causing  an 
intense  burning  pain.  There  is  a  slow  extension  till  the  entire 
foot  becomes  hard,  dry,  black,  and  mummified. 

How  do  you  treat  dry  gangrene  ? 

Disinfect  the  part  and  wrap  in  antiseptic  wool  or  cotton.  Al- 
low a  generous  diet.  Give  tonics  and  stimulants  ;  opium  two  or 
three  grains  daily. 

Under  what  circumstances  is  amputation  required  in  gan- 
grene ? 

When  the  line  of  separation  is  formed. 

Immediately,  in  spreading  or  traumatic  gangrene. 

In  gangrene  from  arterial  occlusion,  when  the  seat  of  the 
occlusion  can  be  certainly  determined.  Instance,  wound  or  liga- 
tion of  an  artery. 

In  senile  gangrene,  only  when  the  line  of  separation  has  formed, 
and  exploratory  incision  shows  that  the  arteries  ahove  are  healthy. 


44  ESSENTIALS    OF    SURGERY. 

WOUNDS. 

The  Germ  Theory. 

Outline  the  germ  theory  of  putrefaction. 

Putrefaction  is  the  result  of  the  growth  of  micro-organisms  in 
the  substance  which  putrefies.  These  micro-organisms  are  di- 
vided into — 

1.  Non-pathogenic,  or  those  which  do  not  directly  create  dis- 
ease. 

2.  Pathogenic,  or  disease  creating. 

Among  the  non-pathogenic,  are  included  those  which  can  live 
or  grow  only  in  dead  or  dying  matter,  termed  saplirophytic. 
These  saphrophytic  micro-organisms,  entering  a  wound  in  which 
there  is  much  pent-up  discharge  and  dying  tissue,  rapidly  in- 
crease, and  produce  certain  irritating  substances,  called  ptomames. 
The  absorption  of  ptomaines  into  the  system  gives  rise  to  the 
symptoms  which  are  characterized  as  septic  intoxication^  ptomaine 
fever ^  sapra^mia,  or  septiccemia. 

Pathogenic  micro-organisms  thTiye  not  only  on  dead  matter,  but 
invade  and  destroy  the  living  tissues.  They  may  be  carried 
through  the  circulation  to  all  parts  of  the  body,  increasing  with 
incredible  rapidity  wherever  deposited,  destroying  tissue,  and 
forming  fresh  centres  for  the  production  of  poisonous  products. 
They  enter  the  system,  by  a  process  of  direct  inoculation,  through 
wounds.  Nearly  all  pathogenic  microbes  are  either  micrococci 
(spherical)  or  bacilli  (rod-shaped). 

What  are  the  general  principles  of  antiseptic  treatment  ? 

1.  Prevent  putrefaction.  2.  If  it  has  already  occurred,  stop 
its  further  progress. 

Since  putrefaction  depends  upon  the  presence  of  an  organism, 
and  a  soil  in  which  it  can  grow,  the  indications  for  the  preven- 
tion of  this  process  are — 

1.  Exclude  all  organisms  from  the  wound.  This  may  be  ac- 
complished by  most  minute  attention  to  the  details  of  surgical 
cleanliness. 


WOUNDS.  45 

2.  Berdove  organisms  from  the  wound,  before  the}'^  can  work 
harm,  by  irrigation. 

3.  Destroy  organisms^  by  bichloride  or  other  germicides. 

4.  Bemove  the  soil  in  which  organisms  can  flourish,  by  free 
drainage. 

5.  Prevent  the  formation  of  favorable  soil,  by  avoiding  tension 
or  unnecessary  manipulation,  and  by  careful  dry  dressing. 

What  is  the  distinction  between  antiseptic  and  aseptic  ? 

Aseptic  means  germ  free;  antiseptic  means  germ  destroying. 
The  surgeon  who  does  not  practise  antisepsis  cannot  procure 
asepsis.  An  aseptic  wound  is  the  result  of  antiseptic  treatment. 
Dressings  sterilized  by  heat  have  undergone  as  thorough  anti- 
septic treatment  as  those  saturated  with  bichloride.  By  an 
aseptic  dressing  is  meant  the  application  of  substances  previously 
sterilized,  but  containing,  at  the  time  of  application,  no  germ- 
destroying  agents.  Antiseptic  dressings  contain  germ  destroying 
agents. 

Shock. 

What  is  shock? 

A  lowering  of  the  vital  powers  consequent  on  profound  mental 
or  physical  impression. 

Shock  is  a  vaso-motor  paralysis,  affecting  also  the  heart,  and 
chiefly  the  abdominal  vessels. 

What  are  the  causes  of  shock  ? 

1.  Powerful  mental  impressions,  joy,  grief,  and  fear. 

2.  Mechanical  injury;  traumatism,  especially  of  the  abdomen  ; 
burns,  scalds,  cold  ;  gunshot,  lacerated,  and  contused  wounds. 
As  predisposing  causes  can  be  classed  all  conditions  which 
cause  enfeeblement  of  the  resisting  powers.  Instance,  Bright's 
disease,  sedentary  occupation,  and  hemorrhage. 

What  are  the  symptoms  of  shock  ? 

Pidse  first  slow,  then  rapid,  feeble,  compressible,  and  scarcely 
perceptible. 

Temperature  sub-normal. 


46  ESSENTIALS    OF    SURGERY. 

Surface  cold,  pale,  and  wet. 

Muscular  system  relaxed,  contractility  of  sphincters  lost. 
Patient  lies  in  any  position  in  which  he  may  be  placed.  Decu- 
bitus usually  dorsal. 

Nausea  and  vomitmg  frequently  present. 

Consciousness  and  special  senses  blunted. 

What  is  your  prognosis  in  shock? 

Bad  if  the  temperature  falls  below  96°,  or  if  reaction  is  delayed 
twenty-four  hours. 

What  becomes  of  a  patient  suffering  from  shock  ? 
He  either  collapses  and  dies  from  syncope  or  asthenia,  or  reacts. 

Describe  reaction. 

Healthy  reaction  is  characterized  by  an  increase  in  the  force, 
and  a  diminution  in  the  rapidity  of  the  heart's  beat,  a  rise  of 
temperature,  a  restoration  of  color  to  the  blanched  surface,  and 
disappearance  of  all  the  characteristics  of  shock.  In  other  cases 
reaction  may  take  the  form  of  an  acute  fever,  with  flushed  face, 
injected  conjunctivse,  high  temperature,  restlessness,  jactitation, 
active  or  muttering  delirium,  and  a  full,  throbbing  pulse.  The 
pulse,  however,  is  soft  and  compressible;  the  tongue  is  dry  and 
tremulous;  the  symptoms  are  asthenic,  and  are  liable  to  lapse  again 
into  profound  and  fatal  shock.  This  condition  is  termed  trau^ 
matic  delirium,  and  is  a  condition  of  under  reaction  from  shock. 

How  do  you  treat  shock  ? 

External  warmth  most  important  of  all  treatment.  Hot  bath, 
hot  bricks  or  bottles  applied  along  the  spine,  to  the  epigastrium, 
and  about  the  patient's  body  and  limbs. 

Position.     Dorsal  decubitus  with  head  low. 

Medication.  Atropia  gr.  y^^  and  brandy  5js,  every  thirty 
minutes  hypodermically ;  morphia  gr.  \  if  there  is  great  pain. 
Avoid  medication  by  the  stomach  till  reaction  begins,  as  there 
is  no  absorption.  Hot  coffee,  or  hot,  highly  seasoned  beef  tea 
may  be  given  in  small  doses  by  the  mouth.  When  reaction  has 
fairly  set  in,  stop  stimidating. 

Describe  the  forms  of  traumatic  delirium. 

In  addition  to  the  form  described  as  an  imperfect  reaction 


WOUNDS.  47 

from  shock,  there  is  an  mflammatory^  a  nervous,  and  an  alcoholic 
traumatic  delirium. 

The  inflammatory  form  is  characterized  by  fever  and  sthenic 
symjjtoms  with  either  sthenic  or  asthenic  condition.  It  develops 
in  from  three  to  five  days  after  the  injury,  and  is  really  a  symp- 
tom of  septic  inflammatory  fever.  Treat  as  for  the  fever,  apply- 
ing an  ice  cap  to  the  head. 

The  nervous  and  alcoholic  forms  of  traumatic  delirium  have  the 
same  busy  asthenic  delirium,  the  soft,  full,  quick  pulse,  the 
tremulousness,  and  absence  of  fever,  the  difference  being  that 
the  nervous  is  not  caused  by  alcohol. 

Treatment.  Stimulants,  bromide,  chloral,  morphia.  Clear 
the  bowels,  give  plenty  of  nourishing  liquid  food  highly 
seasoned. 

What  is  secondary  shock  ? 

Symptoms  coming  on  at  varying  times  from  the  primary 
shock,  and  causing  death  from  heart  clot,  are  characterized  as 
secondary  shock. 

Should  you  operate  during  shock  ? 

IS'ot  unless  it  is  for  the  relief  of  a  condition  causing,  or  keep- 
ing up  the  shock.  Instance,  a  strangulated  hernia,  a  bleeding 
artery,  a  depressed  fracture  of  the  skull.  The  rule  is  to  ivait 
for  reaction. 


Wound  Fever. 

What  is  traumatic  fever  ? 

Fever  following  traumatism. 

Several  forms  may  develop,  the  first  of  which  is  the  reactive 
fever  ;  this  follows  the  shock  of  traumatism.  It  develops  a  few 
hours  after  an  injury  or  operation,  and  subsides  in  one  or  two 
days  at  most.  This  is  the  only  form  of  wound  fever  which 
should  develop  in  antiseptic  surgery. 

How  do  other  forms  of  traumatic  fever  develop  ? 

Given  a  wound  in  which  there  is  tension,  or  irritation  from 
other  causes,  or  in  which  a  few  non-pathogenic  microbes  are 


48  ESSENTIALS    OF    SURGERY. 

found,  there  will  be  a  slight  amount  of  inflammation  and  absorp- 
tion, and  the  patient  will  probably  develop  inflammatory  fever, 
appearing  on  the  second  or  third  day,  and  lasting  from  two  to  six 
days.  Should  the  wound  contain  a  large  quantity  of  discharge 
to  which  micro-organisms  have  had  free  access,  septiccemia  or 
septic  intoxication,  from  the  absorption  of  ptomaines,  is  de- 
veloped. If  the  micro-organisms  are  allowed  to  multiply  till 
they  overwhelm  the  tissues  and  enter  the  blood  current,  pyaemia, 
or  septic  fever  attended  with  the  formation  of  metastatic  ab- 
scesses, is  developed. 

What  are  the  symptoms  of  traumatic  inflammatory  fever  ? 

Full,  strong,  rapid  pulse,  increased  temperature  (1000-103°), 
restlessness,  headache,  and  at  times  delirium,  diminished  secre- 
tions, coated  tongue,  anorexia,  and  constipation. 

How  do  you  treat  inflammatory  fever  ? 

Free  the  wound  from  all  tension.  Provide  against  the  possi- 
hility  of  discharge  being  retained-,  irrigate,  thoroughly  with 
1:1000  bichloride  solution,  dust  liberally  with  iodoform,  and 
apply  a  thorough  antiseptic  dressing,  renewing  the  dressing 
daily  till  the  fever  subsides.  Clear  the  bowels;  give  aconite, 
bromide,  or  morphia,  as  required  by  the  symptoms. 

What  is  septicaemia  ? 

A  septic  intoxication,  caused  by  the  absorption  of  the  products 
of  putrefaction.  Hence,  it  is  most  liable  to  occur  in  wounds  not 
treated  antiseptically,  or  in  those  which,  from  their  depth,  ex- 
tent, or  location,  cannot  be  thoroughly  disinfected  and  protected. 
Instance,  compound  fractures,  wounds  involving  the  peritoneum. 

Give  the  symptoms  of  septicaemia. 

Inflammatory  fever  may  run  into  septicaemia,  or  this  affection 
ma'^'  develop  very  shortly  after  the  infliction  of  a  wound. 

Temperature.  Rises  suddenly,  and  is  at  first  very  high  (104°- 
106°),  may  shortly  sink  to  normal  or  below. 

Pulse.  Soft,  rapid,  and  compressible,  becoming  weak  and 
thjeady. 

Bespirations,  rapid  and  shallow. 


WOUNDS.  49 

Nervoils  condition^  heavy,  apathetic,  somnolent.  Karely,  active 
delirium. 

Tongue^  dry,  hard,  and  discolored.  Teeth  covered  with  sordes. 
At  times  j[jTofuse  diarrhoea.  Urine  and  feces  passed  involunta- 
rily.    Death  in  collapse. 

The  wound  is  always  unhealthy,  frequently  sloughing. 

The  septic  poisoning  may  be  so  slight  in  amount  as  to  cause 
scarcely  recognizable  symptoms,  or  may,  within  twenty-four 
hours  of  the  infliction  of  an  injury,  overwhelm  the  system. 

How  do  you  treat  septicsBmia  ? 

Eemove  the  septic  matter,  and  make  the  wound  sterile  by 
irrigation,  or  continuous  baths  with  bichloride  solution.  Elimi- 
nate the  ptomaines  by  a  saline  purge.  Swpport  the  strength  by 
stimulants,  quinine  in  tonic  doses,  nutritious  food  given  fre- 
quently in  small  quantities  ;  milk  and  malt,  peptonoids,  raw  beef 
juice.  Reduce  high  temperature  by  antipyrine,  gr.  x.-xv.,  or 
quinine,  gr.  xx.     Secure  plenty  of  fresh  air  and  sunlight. 

What  is  pysemia? 

A  septic  fever,  characterized  by  the  formation  of  metastatic 
abscesses.  Pathogenic  organisms  (staphylococci  and  strepto- 
cocci) invade  the  blood,  and  are  carried  from  the  infected  area 
to  all  parts  of  the  body,  where  they  are  lodged  as  emboli,  and 
form  new  foci  of  suppuration  and  infection. 

What  is  the  difference  between  traumatic  inflammatory  fever, 
septicaemia,  and  pyaemia  ? 

Simply  a  difference  of  degree.  They  all  depend  upon  the  same 
cause.,  and  are  of  the  same  nature.  They  occur  only  in  infected 
wounds,  and  are  due  to  the  septic  action  of  micro-organisms  and 
their  products. 

What  are  the  symptoms  of  pyaemia? 

Irregularly  recurring  attacks,  characterized  by  a  marTced  and 
prolonged  chill,  associated  with  high  temperature  (104O-106°) ;  fol- 
lowed by  a  brief  hot  stage,  the  patient  manifesting  the  symptoms 
and  signs  of  fever  ;  terminating  in  a  drenching  sweai,  the  tempera- 
ture quickly  falling  to  normal  or  below.  Several  such  attacks 
may  occur  in  a  day.  The  strength  rapidly  fails  ;  the  pulse  h«- 
4 


60  ESSENTIALS    OF    SURGERY. 

comes  weak  and  rapid ;  the  tongue  dry  and  brown  coated ; 
breath  mawkish  ;  metastatic  abscesses  are  detected  in  the  lungs;  the 
wound  is  unhealtliy,  the  discharges  ichorous. 

How  do  you  treat  pysemia  ? 

Thoroughly  cleanse  the  original  source  of  infection  by  irriga- 
tion, curetting,  and  antiseptic  dressing  ;  if  this  be  impracticable, 
as  in  osteomyelitis,  amputate.  Open  and  drain  all  accessible 
abscesses.  Push  stimulants  to  their  fullest  extent,  give  quinine 
in  heroic  doses  (gr.  Ix.  daily),  milk  and  pressed  beef-juice  in  small 
quantities  frequently  repeated.  Provide  for  sun-Ught,  and  open 
air. 

What  is  hectic  fever  ? 

A  continued  remittent  fever,  due  to  septic  absorption  ;  char- 
acterized by  rigors  and  fever  during  the  afternoon  and  evening, 
followed  by  profuse  sweats  and  defervescence  during  the  night. 
The  pulse  is  constantly  rapid^  the  eye  bright,  the  cheek  flushed, 
the  tongue  red  and  dry  at  the  edges,  the  emaciation  progressive. 
Instance,  the  fever  of  consumption. 

How  do  you  treat  hectic  ? 

Remove  the  source  of  septic  absorption,  by  resection,  if  it  is  an 
infected  bone  area  ;  by  incision  and  curetting,  if  it  is  an  abscess. 
Give  tonics,  stimulants,  and  a  full  nourishing  diet.  Change  of  air 
is  beneficial. 

Erysipelas. 

What  is  erysipelas  ? 

An  infective  spreading  inflammation,  attacking  either  the 
skin,  cellular  tissue,  mucous,  or  serous  membranes. 

What  are  the  causes  of  erysipelas  ? 

Predisposing.  Wounds,  particularly  those  which  are  septic, 
together  with  any  local  or  systemic  condition  depressing  to  the 
vital  resistance.  Instance,  kidney  disease,  intemperance,  over- 
crowding, starvation.  Exciting.  Micro-organisms  and  their 
products. 


WOUNDS.  61 

Name  the  varieties  of  erysipelas. 

1.  Cutaueous  or  sim2)le.  2.  Cellulo-cutaneous  or XJ^degmonous. 
3.  Cellular  or  diffuse  cellulitis. 

Describe  simple  erysipelas. 

Constitutional  sym^jtoms.  Rigors,  headache,  and  fever,  the 
temperature  suddenly  rising  to  103°  or  104° ;  with  nausea  and 
vomiting.     The  fever  shortly  assumes  a  typhoid  type. 

Local  symptoms.  A  rash,  rapidly  spreading  from  a  scratch, 
abrasion,  or  wound,  and  characterized  by  well  defined  margins, 
rosy-red  hue,  smooth,  glazed,  oedematous,  slightly  raised  surface, 
stiffness  and  burning  pain,  frequently  hlehs  or  vesicles,  involve- 
ment of  nearest  lymphatic  glands.  The  eruption  may  suddenly 
disappear  from  one  part  to  reappear  in  another,  erysipelas 
amhulans. 

The  pathogenic  organism  of  simple  erysipelas  has  been  isolated. 
It  is  found  blocking  the  lymph  vessels  and  spaces  in  the  spreading 
borders  of  the  inflammation,  shows  up  well  in  dry  cover  glass 
preparations,  appearing  as  micrococci  grouped  in  chains,  and  is 
diagnostic  of  erj'sipelas.  The  eruption  lasts  about  four  days  in 
one  part,  and  as  it  subsides  is  followed  by  desquamation. 

Give  the  treatment  of  simple  erysipelas. 

If  there  is  a  distinct  wound,  thoroughly  cleanse  and  drain  it. 
Freely  open  the  bowels  by  a  saline  cathartic.  Milk  diet  for  the 
first  few  days.  Tr.  fer.  chlor.  TH  xx.  every  two  hours  from  the 
first :  shortly  begin  quinine,  in  tonic  doses  (gr.  v.  to  x.  daily), 
stimulants,  and  as  free  a  diet  as  the  stomach  will  bear. 

To  the  eruption  apply  starch  and  zinc  oxide,  equal  parts  of 
each,  and  cover  in  with  cotton-wool ;  or  apply  a  50  per  cent, 
ichthyol  ointment,  over  which  is  placed  salicylated  cotton. 

Describe  phlegmonous  erysipelas. 

The  skin  and  subcutaneous  tissues  are  both  affected  ;  the 
symptoms  are,  in  general,  the  same  as  for  simple  erysipelas,  but 
more  marked.  The  swelling  is  greater,  the  edges  not  so 
sharply  circumscribed,  the  color  darker,  blebs  and  vesicles  are 
more  common. 

The  surface,  at  first  densely  indurated,  becomes  boggy  in  spots 


52  ESSENTIALS    OF    SURGERY. 

and  may  break  down,  exposing  extensive  sloughs.  The  consti- 
tutional symptoms  are  well  marked,  running  shortly  into  the 
typhoid  type.  The  patient  may  perish  from  pneumonia,  blood 
poisoning,  or  exhaustion. 

How  do  you  treat  phlegmonous  erysipelas  ? 

Constitutionally,  as  in  the  case  of  simple  erysipelas.  A  purge, 
light  milk  diet ;  followed  in  a  day  or  two  by  full  nourishment, 
tonics,  and  stimulants.     Iron  as  before. 

Locally.  Applications  of  heat  and  moisture  (hot  antiseptic 
fomentations).  Multixjle  incisions  as  soon  as  the  part  becomes 
brawny,  going  down  to,  but  not  through  the  deep  fascia.  Check 
hemorrhage  by  packing  with  iodoform  gauze.  Strict  antiseptic 
dressing. 

Describe  cellular  erysipelas,  or  diffuse  cellulitis. 

This  is  a  spreading  infective  inflammation,  which  may  involve 
the  cellular  tissues  of  any  part  of  the  body.  Instance,  the  inter- 
muscular planes,  the  pelvic  cellular  tissues. 

The  constitutional  symptoms  are  the  same  as  those  character- 
izing phlegmonous  erysipelas  ;  the  typhoid  condition  appears 
more  quickly,  and  septic  poisoning  is  more  commonly  developed. 

The  local  symptoms  are  at  first  less  marked  than  in  any  of  the 
varieties  of  erysipelas.  There  is  dense  induration  succeeded  by 
hogginess  and  ending  in  extensive  sloughing. 

Treatment  as  for  cellulo-cutaneous.  Incisions  early.  Stimu- 
lating and  supporting  treatment  from  the  first. 

Tetanus. 

What  is  tetanus? 

A  tonic  spasm  of  the  voluntary  muscles  w^ith  clonic  exacerba- 
tions, due  to  the  introduction  into  the  system  of  an  infective 
poison. 

What  are  the  causes  of  tetanus  ? 

1.  Predisposing.  Hot  climate,  exposure  to  cold  and  damp,  or 
sudden  change  of  temperature,  negro  race,  lacerated  and  punc- 
tured wounds,  burns,  frost-bites,  all  septic  wounds. 

2.  Exciting.     A  micro-organism. 


WOUNDS.  53 

What  are  the  symptoms  of  tetanus? 

A  slight  stiffness  of  the  muscles  of  the  neck  and  jaws,  with 
increase  of  pain,  and  the  appearance  of  a  sanious  or  ichorous  dis- 
charge in  the  wounded  part,  denote  the  onset  of  the  disease. 
All  the  voluntary  muscles,  including  those  of  respiration,  may 
become  involved.  There  is  intense  pr^ecordial  pain  from  tonic 
spasm  of  the  diaphragm,  the  countenance  exhibits  a  peculiar 
grinning  expression  (risus  sardonicus),  and  at  the  slightest  irri- 
tation, such  as  a  breath  of  air,  a  loud  noise,  or  an  attempt  to 
swallow,  violent  spasms  occur  which  may  variously  contort  the 
body.  If  the  spinal  muscles  are  chiefly  affected,  we  have  op«"s- 
thotonos,  or  arching  backward,  the  body  being  supported  on  the 
head  and  heels.  Emprosthotonos  ma}''  be  developed,  the  body 
being  bent  forward  and  rolled  up  like  a  ball.  More  rarely  pZew- 
rosthotonos,  or  drawing  of  the  body  to  one  side,  is  seen.  The 
skin  is  wet,  the  bowels  confined,  the  temperature  about  normal ; 
it  may  rise  to  108^  or  110^  shortly  before  death.  Intellect 
clear. 

What  is  the  prognosis  of  tetanus  ? 

Bad  in  acute  cases  ;  becomes  more  favorable  if  life  be  pro- 
longed till  the  twelfth  day.  Death  occurs  from  spasm  of  the 
glottis  or  respiratory  muscles,  from  syncope,  from  exhaustion. 

What  are  the  diagnostic  points  of  tetanus  ? 

The  absence  of  fever  from  the  first,  the  tonic  charf/cter  of  the 
spasm,  the  early  involvement  of  the  neck  and  jaw,  the  marlied 
convulsive  attacks,  and  the  clear  mind. 

Give  the  treatment  of  tetanus. 

Local.  Make  the  wound  aseptic.  Amputation,  nerve  cutting, 
or  nerve  stretching,  have  also  been  advised. 

Constitutional.  Bromide  of  potassium  up  to  its  constitutional 
eflect  (40  to  80  grains  every  two  hours),  chloral  at  night  to  pro- 
duce sleep.  Morphia  may  be  given  ;  it  must  be  pushed  to  the 
extreme  limit  of  safety.  To  prevent  death  from  asphyxia  give 
chloroform  during  the  spasm.  Stimulants,  and  nourishing  diet 
are  indicated  from  the  first. 


54  ESSENTIALS    OF    SURGERY. 


Hydrophobia. 

What  is  hydrophobia  ? 

A  disease  due  to  a  specific  poison  introduced  into  the  system 
by  the  bite  of  a  rabid  animal. 

What  bites  are  especially  liable  to  be  followed  by  hydrophobia? 
Those  on  the  face,  or  involving  parts  of  the  body  unprotected 
by  clothing. 

What  is  the  period  of  incubation  ? 

It  varies  from  six  weeks  to  three  months  ;  it  may  be  a  very 
few  days,  or  many  years. 

What  are  the  symptoms  of  hydrophobia  ? 

First  stage,  or  stage  of  melancholia,  itching,  burning,  or  inflam- 
mation of  the  cicatrized  wound  ;  anxiety,  melancholia,  or  change 
of  disposition  ;  slight  difficulty  in  swallowing,  or  a  catch  in  the 
respiration.  After  a  few  days  the  disease  is  fully  developed. 
The  stage  of  excitement  is  characterized  by  clonic  convulsions, 
involving  especially  the  muscles  of  respiration  and  deglutition  ; 
by  mental  disorder  similar  to  that  of  delirium  tremens,  with 
periods  of  maniacal  excitement,  and  intervals  of  lucidity.  It  is 
followed  after  some  days  by  the  stage  of  exhaustion  and  paralysis. 
The  muscular  system  is  entirely  unresponsive,  and  the  dying  pa- 
tient lies  motionless  ;  the  mind  is  often  clear  at  this  stage. 

How  do  you  treat  hydrophobia  ? 

At  the  time  the  ivound  is  inflicted,  cauterize,  at  once  and  thor- 
oughly, by  hot  iron,  nitric  acid,  or  caustic  potash.  Such  the  looiind. 
If  the  wound  has  cicatrized  when  seen,  excise  the  cicatrix.  Send 
the  patient  where  he  can  be  inoculated  after  Pasteur's  method 
with  attenuated  virus. 

Wlien  the  symptoms  are  pronounced,  morphia,  chloral,  chloro- 
form to  relieve  suffering.  Pilocarpine  gr.  ^  hypodermically, 
repeated  frequently.    Hot  vapor  bath. 


WOUNDS.  55 

Glanders. 

What  is  glanders  ? 

An  infective  disease  of  horses,  dependent  on  a  specific  micro- 
organism ;  communicable  to  man  through  wounds,  or  the  mu- 
cous membrane.  In  horses  it  is  called  glanders  when  it  attacks 
the  nasal  mucous  membrane,  farcy  when  it  attacks  the  lymphatic 
vessels  and  glands. 

What  are  the  symptoms  of  glanders  ? 

A  discharge  from  the  nose,  thin,  sanious,  offensive,  purulent, 
with  involvement  of  the  submaxillary  glands.  A  pustular  erup- 
tion resembling  smallpox,  involving  the  skin  and  the  mucous 
membrane  of  the  respiratory  and  alimentary  tracts.  Sub-cutane- 
ous nodules,  shortly  breaking  down  and  forming  foul  ulcers. 
There  is  fever,  which  quickly  becomes  adynamic,  and  death 
takes  place  within  a  week  from  septicaemia  or  pyaemia.  There  is 
a  chronic  form  of  glanders  with  less  marked  symptoms,  and  from 
which  recovery  is  possible. 

How  do  you  treat  glanders  ? 

Use  antiseptic  nose  washes  (boracic  acid  or  weak  bichloride 
solution).  Open  abscesses.  Pursue  from  the  first  a  tonic,  stimu- 
lating, and  supporting  treatment. 


Malignant  Pustule. 

What  is  anthrax  ? 

A  specific  infective  disease  due  to  the  entrance  of  a  bacillus 
or  its  spores  into  the  system.  Its  starting-point  is  in  a  scratch 
or  abrasion.  It  is  found,  in  this  country,  mainly  among  those 
who  handle  imported  hides  or  wool. 

What  are  the  symptoms  of  anthrax  ? 

A  red,  itching  pimple,  followed  shortly  by  a  vesicle  attended 
with  well-marked,  brawny  induration.  Sloughing  begins  at  once, 
and  the  anthrax  pustule  is  formed,  characterized  by  a  dry,  central 
slough,  surrounded  by  a  ring  of  vesicles,  peripheral  to  which  there 


56     '  ESSENTIALS    OF    SURGERY. 

is  an  area  of  redness,  induration,  and  great  cedema.  The  neigh- 
boring lymphatic  glands  are  involved.  Fever  of  an  adj^namic 
type  develops,  and  the  patient  commonly  perishes  of  exhaustion 
or  syncope.  Diagnosis  b}^  examining  the  contents  of  the  vesicle  *, 
bacilli  from  ^^^o  to  y^igj  of  an  inch  in  length  can  be  detected  by 
low  powers  of  the  microscope. 

How  do  you  treat  malignant  pustule  ? 

Freely  excise  the  pustule,  and  either  cauterize  the  wound  with 
caustic  potash  or  carbolic  acid,  or  wash  thoroughly  and  repeatedly 
with  5  per  cent,  potassium  permanganate  solution.  A  stimu- 
lant, tonic,  and  supporting  treatment  is  indicated  constitution- 
ally. 

The  Healing  of  Wounds. 

Describe  the  process  of  repair  in  incised  wounds. 

Bexjair  talces  %)lace  in  all  icounds  hy  the  organization  of  plastic 
lymjjk. 

If  the  wound  is  an  incised  one,  if  its  surfaces  are  accurately 
approximated,  if  it  is  not  subject  to  irritation,  either  mechanical 
or  chemical,  the  exudation  takes  place  in  minimum  quantity, 
the  red  blood  corpuscles  of  the  blood  clot  are  absorbed ;  in 
twenty-four  hours  the  surfaces  adhere,  and  in  two  or  three 
days  the  thin  layer  of  plastic  lymph  which  binds  them  together 
is  supplied  with  vessels  ;  this  is  called  union  hy  adhesion  w  by 
first  intention.  Inflammation  scarcelj^  passes  the  first  stage; 
there  is  simply  a  little  hj-pertemia,  puflaness,  and  tenderness 
about  the  lips  of  the  wound. 

If  the  wound  surfaces  are  not  accurately  apposed,  if  they 
are  subject  to  irritation,  either  mechanical,  from  improper 
dressing,  or  chemical,  from  irritating  applications  or  the  pro- 
ducts of  germ  life,  the  exudation  becomes  excessive  ;  there  is 
death  of  tissue,  there  is  suppuration  ;  if  tension  and  other 
sources  of  irritation  be  removed  by  free  discharge,  the  gap  is 
promptly  filled  in  with  organized  plastic  lymph  or  gramdations, 
and  the  wound  heals  by  granulation  or  second  intention. 

If  healthy  granulating  surfaces  can  be  brought  together  and 


WOUNDS.  57 

retained  in  position,  permanent  adhesion  between  tbem  takes 
place  at  once.  This  constitutes  union  by  secondary  adhesion  or 
third  intention. 

Primary  adhesion  or  first  intention.  The  prompt  union  of 
divided  surfaces  witliout  obvious  signs  of  inflammation. 

Adhesion  by  granidation  or  second  intention.  The  union  of 
divided  surfaces  by  granulation  tissue  (organized  lymph),  at- 
tended with  evident  inflammatory  symptoms. 

Secondary  adhesion  or  third  intention.  The  union  of  granula- 
ting surfaces.  Amputation  flaps  which  fail  to  unite  by  primary 
intention  heal  in  this  way. 

What  circumstances  prevent  wounds  from  healing  by  primary 
intention? 

1.  Want  of  accurate  apposition ;  from  gaping,  from  extensive 
loss  of  substance,  from  retained  blood  or  wound  secretions,  or 
from  foreign  body. 

2.  Want  of  proper  protection.  There  may  be  undue  motion  of 
the  part,  it  may  be  subject  to  direct  mechanical  or  chemical 
violence,  it  may  be  exposed  to  infection  from  poisonous  agents. 

3.  Defective  nutrition,  either  local,  from  bad  position  or  from 
tension,  or  general  from  constitutional  weakness. 

The  Treatment  of  Wounds. 

What  are  the  general  indications  in  the  treatment  of  wounds? 

1.  Arrest  hemorrhage. 

2.  Cleanse,  and  remove  foreign  bodies. 

3.  Provide  for  drainage. 

4.  Bring  the  wounded  surfaces  in  contact,  and  keep  them 
apposed. 

o.  Provide  for  absolute  local  rest. 
6.  Prevent  putrefaction. 

Name  the  varieties  of  hemorrhage. 

Arterial,  Venous,  Capillary.  Internal  or  concealed  hemorrhage 
indicates  bleeding  into  one  of  the  cavities  of  the  body.  Ex- 
travasation indicates  bleeding  into  the  areolar  tissue.  Further, 
hemorrhage  may  ha  primary ,  intermediate  or  consecutive,  secondary. 


68  ESSENTIALS    OF    SURGERY. 

What  are  the  characteristics  of  the  different  kinds  of  hemor- 
rhage ? 

Arterial.  Bright  red  blood  jets  from  the  wound.  Pressure 
on  the  arterial  trunk  above  checks  the  bleeding. 

Venous.  Dark  blood  wells  from  the  wound.  Pressure  on  the 
venous  trunk  helow  checks  the  bleeding. 

Capillary.  The  blood  oozes  from  the  surface  of  the  wound, 
and  collects  as  a  pool  in  its  deeper  parts. 

What  are  the  constitutional  effects  of  hemorrhage? 

A  feeble,  fluttering,  rapid  pulse,  finally  perceptible  in  the 
large  arteries  only.  A  cold,  blanched,  wet  surface,  with  colorless 
lips,  and  sighing  respiration.  Nausea.  Frequently,  uncontrol- 
lable restlessness,  a  roaring  in  the  ears,  darkness  before  the  eyes, 
and  horrible  sinking  sensations.  The  patient  may  suddenly 
faint.  In  syncope  the  heart's  action  is  so  feeble  that  clotting 
may  take  place  and  bleeding  be  permanently  arrested,  or,  on  re- 
action, the  clot  may  be  w.ashed  away  by  the  returning  blood 
current  and  bleeding  continue,  to  end  in  a  return  of  syncope, 
in  convulsions  and  death.  Or  the  patient  may  recover,  passing 
into  the  condition  known  as  hemorrhagic  fever,  an  irritative  fever 
characterized  by  rise  of  temperature,  extreme  restlessness,  great 
thirst,  and  a  quick  jerky  pulse. 

A  sudden  violent  hemorrhage  is  much  more  liable  to  produce 
fatal  syncope  than  a  slow  continuous  one.  Infants  bear  the  loss 
of  blood  very  badly. 

Describe  nature's  method  of  arresting  hemorrhage. 

1.  Contraction  and  retraction  of  the  vessels. 

2.  Coagulations  of  the  blood  aided,  after  severe  bleeding,  by 
enfeebled  heart  action  and  alteration  in  the  composition  of  the  blood. 

On  cutting  an  artery  the  muscular  fibres  of  its  midddle  coat 
contract,  narrowing  or  closing  the  lumen  and  drawing  the  end 
of  the  vessel  from  its  sheath  ;  the  cut  ends  also  retract  from  each 
other,  owing  to  the  natural  elasticity  of  the  artery.  Neither  con- 
traction nor  retraction  can  take  place  unless  the  artery  is  entirely 
cut  across;  hence,  complete  section  of  a  bleeding  artery  often 
stops  the  hemorrhage. 


WOUNDS.  59 

Coagulation  is  excited  by  the  divided  vessel  wall,  the  sheath 
of  the  artery,  and  the  air  ;  it  presently  occludes  the  opening  in 
the  artery,  and  also  fills  with  clot  the  space  left  vacant  in  the 
sheath  by  retraction  ;  this  constitutes  external  dot.  Coagulation 
also  extends  from  the  mouth  of  the  vessel  backward,  forming  a 
clot,  conical  in  shape,  with  its  base  to  the  wound,  and  extend- 
ing as  far  as  the  nearest  branch ;  this  constitutes  the  internal 
clot. 

By  continued  hemorrhage  the  blood  is  made  more  coagulahle  ; 
a  clot  forms  too  rapidly  to  be  washed  away  by  the  feeble  arterial 
wave.  Arrest  of  hemorrhage  from  veins  is  due  to  coagulation. 
The  permanent  arrest  of  hemorrhage  is  effected  by  the  exudation 
of  plastic  lymph.^  which  takes  the  place  of  the  clot,  the  subsequent 
organization  of  this  lymph,  and  the  conversion  of  the  occluded 
part  of  the  artery  into  a  fibrous  cord. 

What  is  the  constitutional  treatment  of  hemorrhage  ? 

The  patient  should  be  laid  fiat  on  his  back  ;  if  the  symptoms 
are  very  severe,  elevate  the  foot  of  his  bed  and  apply  an  Esmarch's 
bandage  to  the  legs  and  arms,  thus  keeping  the  blood  to  the 
nerve  centres.  Hot  bottles  may  be  applied  about  the  body.  In 
extreme  cases  resort  to  transfusion.  Ether  TTlxxx.,  morphia 
gr.  ^,  should  be  given  subcutaneously.  Place  a  mustard  plaster 
over  the  heart.  Give  injections  of  hot  water  and  brandy.  Hot 
coffee  or  beef  tea  in  frequently  repeated  small  doses  by  the  mouth, 
if  the  stomach  is  retentive.  As  the  patient  recovers  stop  stimu- 
lants. Give  milk  diet  at  first,  increasing  as  rapidly  as  possible. 
Give  iron  as  soon  as  the  stomach  will  allow  of  its  use.  In  all 
cases  avoid  stimulants  unless  life  is  directly  threatened  hy  cardiac 
failure.  The  use  of  stimulants  is  frequently  attended  by  a  re- 
turn of  bleeding. 

Describe  the  methods  of  transfusion. 

Blood  or  saline  solutions  may  be  used.  It  must  be  introduced 
warm  [W^-lOiP),  in  sufficient  quantity  to  add  strength  and 
volume  to  the  pulse,  and  must  not  contain  bubbles  of  air.  Trans- 
fusion may  be  immediate,  the  blood  being  passed  directly  from 
the  vein  of  the  donor  to  the  patient's  circulation  ;  or  mediate^  the 
blood  being  first  whipped  and  strained  of  its  fibrin,  then  injected. 


60  ESSENTIALS    OF    SURGERY. 

How  do  you  check  hemorrhage  ? 

By  1.  Position.  2.  Cold.  3.  Heat.  4.  Pressure.  5.  Styp- 
tics. 6.  Cautery.  7.  Ligation.  8.  Torsion.  9.  Acupressure. 
10.  Porcipressure.     11.  Constitutional  treatment. 

What  position  favors  the  checking  of  hemorrhage  ? 

Elevation  of  the  part  and  forcible  flexion.  Plexion  bends  the 
artery  sharply  on  itself,  and  is  applicable  to  wounds  of  the  ex- 
tremities. 

Describe  the  use  of  cold  as  a  haemostatic. 

Used  only  to  check  bleeding  from  smaller  vessels.  It  causes 
contraction  and  coagulation.  Ice,  ice-water  as  a  fine  forcible 
stream  directed  against  the  bleeding  point. 

Describe  the  use  of  heat  as  a  haemostatic. 

Used  to  check  general  oozing  from  large  surfaces.  It  causes 
contraction  and  coagulation.  Apply  in  the  form  of  large  com- 
presses wrung  out  in  hot  (1200-140°)  water. 

Describe  the  use  of  pressure  as  a  haemostatic. 

A  graduated  compress  and  a  bandage  may  be  used  for  the 
permanent  arrest  of  hemorrhage  when  other  means  are  not  avail- 
able, or  when  several  vessels  are  bleeding  and  there  is  a  firm 
bone  against  which  to  make  pressure.  Instance,  wounds  of  the 
palm  or  of  the  scalp. 

As  a  temporary  means  of  checking  bleeding  the  finger  in  the 
wound  is  most  eflicient,  the  hemorrhage  from  any  accessible 
artery  can  be  checked  in  this  way.  The  tourniquet  and  Es- 
march's  rubber  tube  are  also  of  temporary  service. 

Describe  the  use  of  styptics  as  haemostatics. 

Act  by  coagulating  the  blood,  they  also  contract  the  arteries. 
They  must  be  brought  into  immediate  contact  with  the  bleeding 
vessel.  They  all  interfere  with  primary  union.  Use  powdered 
alum,  tannin,  gallic  acid,  or  persulphate  of  iron  ;  solutions  of 
the  same  drugs,  especially  hot  saturated  solutions  of  alum  may 
be  employed  ;  alcohol,  turpentine,  chloroform  are  also  recom- 
mended. Chiefly  useful  in  checking  bleeding  from  malignant 
ulcers,  or  in  inaccessible  regions.  Styptics  should  be  employed 
in  conjunction  with  pressure. 


WOUNDS.  61 

Describe  the  use  of  the  actual  cautery  as  a  haemostatic. 

It  coagulates  the  blood,  causes  contraction  of  the  muscular 
coat  of  the  artery,  and  forms  an  eschar  which  acts  mechanically. 
If  the  actual  cautery  is  used,  it  should  not  be  heated  beyond  a 
dull  red.  Secondary  hemorrhage  may  occur  when  the  eschar 
separates.  Applicable  where  there  is  difficulty  in  placing  liga- 
tures. Instance,  in  operation  about  the  bones  of  the  face. 
Paquelin's  cautery  or  the  galvano  cautery  should  be  used. 

Describe  ligation  as  a  means  of  arresting  hemorrhage. 

This  is  the  most  important  of  all  haemostatic  agents.  By  the 
pressure  of  the  thread,  the  middle  and  internal  coats  are  divided, 
and  curl  up  within  the  vessel,  causing  clotting  ;  this  clotting 
extends  to  the  first  lateral  branch. 

If  the  artery  is  ligated  in  its  continuity,  a  conical  clot  is  formed 
on  both  the  distal  and  proximal  sides  of  the  ligature,  with  the 
apex  in  each  case  pointing  away  from  the  thread. 

About  the  ligature  there  is  deposited  a  layer  of  plastic  lymph  ; 
the  internal  clot  becomes  infiltrated  with  leucocytes  and  or- 
ganizes ;  the  ligature,  if  aseptic,  is  either  absorbed  or  encysted, 
and  the  artery  is  converted  into  a  fibrous  cord.  If  the  ligature 
is  septic,  or  subject  to  irritation,  it  separates  by  ulceration;  this 
separation  may  be  accompanied  by  secondary  hemorrhage. 

What  precautions  are  observed  in  applying  a  ligature? 

It  must  be  aseptic.  It  should  include  only  the  vessel.  If  ap- 
plied to  an  artery  in  its  continuity,  a  healthy  part  of  the  vessel 
must  be  selected  ;  a  square  knot  should  be  tied. 

Of  what  should  ligatures  be  made? 

Carbolized  and  chromicized  catgut ;  carbolized  silk. 

Describe  the  method  of  applying  torsion  as  a  haemostatic. 

Torsion  consists  in  seizing  the  artery  in  torsion  forceps,  draw- 
ing it  from  its  sheath  and  twisting  till  the  inner  and  middle 
coats  give  way.  It  is  efficient  for  even  the  largest  arteries,  but 
takes  more  time  than  other  methods. 

Describe  acupressure. 

This   consists  in   checking  hemorrhage  by  compressing  the 


62 


ESSENTIALS    OF    SURGERY. 


wounded  vessel  between  an  acupressure  needle  and  the  tissues. 
The  methods  of  accomplishing  this  are  by — 

1.  Circumdusion.  A  pin  or  needle  is  thrust  through  the  tissues, 
beneath  the  arter}^  and  brought  out  to  the  surface  on  the  opposite 
side.  If  necessary  a  thread  can  be  carried  around  the  two  ex- 
tremities of  the  pin  in  the  form  of  a  figure-of-S.  The  hare-lip 
suture  is  really  an  application  of  circumdusion. 

2.  Torsoclusion.  The  pin  transfixes  the  tissues  parallel  to  the 
artery,  is  twisted  till  it  lies  at  right  angles  to  its  former  direc- 
tion, is  pushed  directly  across  the  artery,  and  plunges  into  the 
tissues  on  the  opposite  side. 

3.  Betrodusion.  The  needle  is  carried  in  and  out,  transfixing 
the  tissues  on  one  side  of  the  artery  and  at  right  angles  to  its 
course.  The  point  of  the  needle  is  then  carried  over  the  artery 
to  the  opposite  side,  is  plunged  directly  downwards,  is  carried 

under  the  artery  and  its  point  makes  its 
^^S'  !•  appearance  on  the  side  from  which  it 

originally  started. 

Describe  forcipressure. 

Forcipressure  consists  in  seizing  the 
end  of  the  bleeding  vessel  in  hsemostatic 
forceps,  which  are  allowed  to  remain  in 
place  till  either  the  end  of  the  opera- 
tion, or  till  the  forceps  are  required  in 
another  place,  when  they  should  be 
gently  removed.  The  artery  is  crushed  ; 
the  middle  and  inner  coats  break  as  in 
ligation. 

What  drugs  may  be  administered  by 
the  mouth  for  the  arrest  of  hem- 
orrhage ? 

Opium,  ergot,  ol.  erigeron.,  acid, 
sulph.  aromat. 

What  is  primary  hemorrhage  ? 

Bleeding  which  occurs  immediately, 
Hemostatic  forceps.  on  the  infliction  of  a  wound. 


WOUNDS.  63 

What  is  recurrent  hemorrhage  ? 

Synonyms  :  Reactionary,  consecutive,  intermediate. 
Bleeding,  which  comes  on  with  reaction.     It  occurs  within  the 
first  twenty-four  hours  after  a  wound. 

What  are  the  causes  of  recurrent  hemorrhage? 

The  sli2')xn'ng  of  a  ligature.  The  flhY)lo.cement  of  a  clot.  This 
may  occur  from  the  wounded  part  not  being  kept  at  rest,  or  from 
the  increased  force  of  reaction  circulation. 

How  do  you  treat  recurrent  hemorrhage? 

First  elevate,  and  apply  firm  pressure  by  means  of  additional 
bandages,  covering  in  the  soiled  dressings  with  antiseptic  gauze. 
If  bleeding  still  continues,  remove  the  dressing,  open  the  wound, 
clear  out  the  clots,  and  ligate  or  secure  the  bleeding  vessel. 

What  is  secondary  hemorrhage? 

Bleeding  which  comes  on  between  the  end  of  the  first  day  and 
the  complete  cicatrization  of  the  wound.  It  is  most  frequent 
about  the  time  of  the  separation  of  ligatures  or  sloughs. 

What  are  the  causes  of  secondary  hemorrhage  ? 

1.  Constitutional  conditions  which  interfere  with  organization, 
or  are  associated  with  an  overacting  heart.  Instance,  Bright's 
disease,  diabetes,  haemophilia,  traumatic  delirium,  septicaemia, 
pysemia,  and  plethora. 

2.  Disease  of  the  arterial  walls,  as  found  in  atheroma,  calcare- 
ous degeneration,  syphilis,  or  tuberculosis. 

3.  Se^jtic  condition  of  the  wound.  The  ulceration  and  sloughing 
may  involve  the  arterial  walls. 

4.  Defect  in  the  ligature  or  its  application.  The  ligature  may 
soften  prematurely.  It  may  be  septic  and  cause  suppuration. 
It  may  be  badly  applied,  being  too  loose,  or  irregularly  knotted, 
or  tied  too  near  a  collateral  branch. 

How  do  you  treat  secondary  hemorrhage  ? 

If  from  a  severed,  artery,  as  in  a  stump,  and  only  a  few  days 
have  elapsed  since  the  infliction  of  the  wound,  treat  as  consecu- 
tive hemorrhage  ;  that  is,  try.  elevation  and  pressure  first,  if  the 
bleeding  be  moderate,  that  failing,  or  at  once,  in  case  of  violent 


64  ESSENTIALS    OF    SURGERY. 

hemorrhage,  reopen  the  wound  and  secure  the  vessel.  If  there 
is  much  sloughing  use  the  actual  cautery. 

Later,  when  the  healing  is  well  advanced,  try  pressure  first, 
then  either  reopen  the  wound,  or  ligate  the  main  artery  just 
above.     If  the  bleeding  recurs  amputate  higher  up. 

If  from  an  artery  tied  in  its  continuity.  Pressure  by  graduated 
compresses  and  compression  of  the  artery  above.  If  this  fails 
open  the  wound  and  tie  above  and  helow.  Should  the  bleeding  still 
persist  amputate^  if  the  femoral  artery  is  the  one  involved,  or 
tie  above,  in  the  case  of  other  arteries. 

How  do  you  cleanse  wounds  ? 

Gross  foreign  particles  can  be  picked  out  with  forceps.  Blood 
clots  and  dust  should  be  washed  away  by  means  of  a  fine  stream 
of  sterile  or  antiseptic  liquid ;  avoid  all  rough  handling  or 
rubbing. 

How  do  you  provide  for  drainage  ? 

By  means  of  drainage  tubes,  which  may  be  made  of  red  rub- 
ber, glass,  or  decalcified  bone  ;  or  by  strands  of  catgut  or  horse- 
hair. Drainage  does  not  allow  the  serous  exudate  to  make 
tension  in  the  wound,  or  to  remain  as  a  rich  culture  fluid  for  the 
reception  of  germs.  It  should  be  employed  in  all  wounds  ex- 
cept those  which  are  superficial,  or  are  placed  in  very  vascular 
regions,  as  in  the  face.  Drainage  tubes  are  to  be  removed  in 
from  24  to  48  hours.  If  the  wound  is  very  deep  and  extensive 
take  the  tubes  out  gradually.  The  tube  should  be  carried 
through  the  protective,  should  be  cut  oflT  flush  with  the  surface, 
and  should  be  prevented  from  slipping  into  the  wound  by  silver 
wire  or  a  safety  pin. 

How  do  you  close  wounds  ? 

Both  edges  and  surfaces  must  be  approximated.  In  superficial 
wounds  adhesive  plaster,  isinglass  plaster,  or  gauze  collodion 
and  iodoform  may  be  used.  In  deep  w^ounds  sutures  must  be 
employed  together  with  compresses  and  bandages. 

Of  what  materials  are  the  ordinary  sutures  made  ? 

Silk,  silver  wire,  catgut,  horsehair. 


WOUNDS.  65 

Describe  the  various  kinds  of  suturing. 

1.  The  continuous  {glover''s).     The  stitches  are  made  with  one 
unbroken  thread,  carried  across  the  wound  in  one  direction. 

2.  The  interrupted.     Each  stitch  is  carried  across  the  wound 
and  tied  as  inserted. 

Fig.  2. 


Interrnpted  sutures. 

3.  Pin  suture  (twisted  or  hare-lip).  The  apposed  margins  of 
a  wound  are  transfixed  with  pins,  around  the  two  ends  of  which 
and  across  the  wound  is  carried  a  thread  in  the  form  of  a  fig- 
ure-of-eight. This  keeps  the  surfaces  in  accurate  apposition, 
and  checks  bleeding  (circumchision). 

4.  The  quill  suture.  Threads  are  passed  deeply  across  the 
wound  and  looped  around  quills  or  sections  of  catheter,  placed 
parallel  to  the  wound  and  at  some  little  distance  from  its  edges. 

The  button  or  plate  suture.  Wire  is  passed  across  the  very  bot- 
tom of  the  wound,  brought  out  to  the  surface  at  some  distance  from 
its  edges,  and  secured  by  fastening  to  leaden  plates  or  buttons. 

The  Lembert  and  Czerny  sutures  will  be  described  under 
intestinal  wounds. 

When  there  is  much  gaping,  or  loss  of  substance,  the  plate  or 
quill  sutures  are  used,  they  prevent  tension  in  the  skin  sutures, 
and  arc  termed  sutures  of  relaxation.  If  the  wound  is  moder- 
ately deep,  a  number  of  interrupted  sutures  are  passed  across 


6Q  ESSENTIALS    OF    SURGERY. 

it  to  its  bottom  and  brought 
out  at  some  little  distance 
from  its  edges,  these  are 
termed  sutures  of  approxima- 
tion. The  skin  is  accurately 
joined  by  closely  applied  super- 
ficial sutures,  either  interrupt- 
ed or  continuous,  called  sutures 

Sutures  of  approximation  and  coaptation.      OJ  coaptation. 

Unless  there  is  great  ten- 
sion, and  reason  to  fear  gaping,  remove  sutures  about  the  fourth 
day. 

How  do  you  prevent  putrefactive  or  infective  processes  in  the 
wound  ? 
By  antiseptic  treatment  and  dressing. 

Describe  the  antiseptic  treatment. 

There  must  be  provided  hasins  for  the  sponges.  Shallow  trays 
for  the  instruments.     A  fountain  syringe  for  irrigation. 

Solutions.  Carbolic  acid  1 :  20.  Bichloride  of  mercury  1 :  500. 
These  solutions  can  be  weakened  by  the  addition  of  water  as 
required. 

Sponges  and  drainage  Uibes  which  have  been  kept  in  carbolic 
acid  1 :  30. 

Ligatures  and  sutures  which  have  been  rendered  aseptic  and 
are  kept  in  absolute  alcohol. 

The  surgeon  prepares  himself  by  scrubbing  his  arms,  hands, 
and  nails  with  a  brush,  sublimate  soap,  and  hot  water ;  puts  on 
his  antiseptic  coat  and  again  washes  his  hands  in  sublimate 
solution  1 :  500. 

The  patient  is  ])repared  by  a  general  hot  soap  bath,  if  possible. 
The  entire  region  of  the  wound  of  operation  is  scrubbed  with  hot 
water  and  sublimate  soap,  shaved,  and  irrigated  with  1:500 
sublimate  solution. 

All  portions  of  the  patient's  body  and  the  operating  table 
near  the  seat  of  injury  are  covered  with  towels  wet  in  1 :  500 
sublimate  solution.     Instruments  and  drainage  tubes  are  placed 


WOUNDS 


6T 


in  1 :  30  carbolic  solution.  The  sponges 
are  put  in  a  basin  and  covered  with  bi- 
chloride, of  the  strength  used  for  irriga- 
ting. The  fountain  syringe  is  filled 
with  bichloride  1:2000.  The  dress- 
ings are  cut  to  the  proper  size,  and 
wrapped  in  bichloride  towels. 

During  the  operation  or  manipulation, 
irrigate  occasionally  with  the  bichloride 
solution,  finally  flushing  out,  if  the 
wound  be  large,  with  a  weak  solution, 
sterile  water  or  salt  solution.  Carefully 
guard  against  instruments,  sponges,  or 
hands  coming  in  contact  with  non- 
sterilized  surfaces. 

At  the  termination  of  the  operation, 
see  that  the  hemorrhage  is  absolutely 
stoppjed,  and  that  drainage  is  amply  pro- 
vided for.     Apply  the  dressing. 

Describe  the  antiseptic  dressing^. 

Lister''s  dressing.  Dust  with  iodoform, 
tective  (varnished  silk),  wet  in  1 :  40  carbohc,  just  large  enough 
to  cover  the  closed  wound.  Over  the  protective,  and  overlap- 
ping it,  place  several  layers  of  carbolized  gauze,  wrung  out  in 
the  1 :  40  solution.  Over  this  deep  dressing  and  overlapping  it, 
apply  six  layers  of  dry  carbolized  gauze,  a  seventh  of  Mackin- 
tosh (rubber  cloth),  an  eighth  of  gauze.  Over  the  whole  and 
about  the  edges  place  antiseptic  cotton,  and  cover  in  with  a  car- 
bolized gauze  bandage.  The  protective  guards  the  wound  sur- 
faces from  the  irritation  of  the  strongly  carbolized  gauze.  The 
deep  wet  dressing  disinfects  the  immediate  neighborhood  of  the 
wound  ;  it  is  wet  because  dry  cold  gauze  may  contain  septic 
particles  of  dust.  The  Mackintosh  prevents  the  discharge  from 
passing  through  the  gauze  immediately  to  the  surface. 

The  dressing  in  ordinary  use  is  :    1.  Dry  iodoform  gauze  to 
the  wound.     2.  Covered  and  overlapped  by  bichloride  gauze. 


Sutures. 


Apply  a  piece  of  pro- 


68  ESSENTIALS    OF    SURGERY. 

3.  Bichloride  cotton  overlapping  the  whole  and  covered  in  by  a 
gauze  bandage. 

When  do  you  change  an  antiseptic  dressing  ? 

1.  When  drainage  tubes  or  non-absorbable  sutures  are  to  be 
removed. 

2.  When  fever,  other  than  that  due  to  reaction,  appears. 

3.  When  there  is  hemorrhage. 

4.  When  the  wound  is  healed. 


Wounds. 

What  is  a  wound? 

A  solution  in  the  continuity  of  the  tissues,  produced  by  sudden 
force. 

Under  what  two  headings  may  wounds  be  classed  ? 

1.  Subcutaneous  luoimds.  There  is  either  no  break  in  the  skin 
or  an  exceedingly  small  one  compared  to  the  extent  of  the  lesion 
beneath.  Instance,  the  wound  of  tenotomy  is  said  to  be  subcu- 
taneous. 

2.  Open  wounds.  The  break  in  the  surface  is,  to  a  certain  ex- 
tent, commensurate  to  the  deeper  injury. 

What  is  a  contusion  ? 

A  subcutaneous  injury  (distinguish  from  contused  wound,  in 
which  there  is  a  break  in  the  surface)  occasioned  by  squeezing 
or  crushing  the  tissues.  There  is  hemorrhage  and  discoloration, 
at  times  vesicles  and  blebs  form,  and  the  part  may  appear  gan- 
grenous. The  effused  blood  may  form  a  fluctuating  swelling, 
known  as  hoematoma^  or  may  coagulate,  forming  a  hard  swelling, 
termed  thrombus. 

How  do  you  treat  contusion? 

By  rest,  pressure,  and  the  application  of  evaporating  and 
stimulating  lotions. 

Name  the  different  kinds  of  open  wounds. 

1.  Incised,  or  clean  cut.    2.  Lacerated,  or  torn.    3.  Contused, 


WOUNDS.  69 

or  bruised.    4.  Punctured,  or  pierced.    5.  Gunshot,  or  lacerated 
and  contused.     6.  Poisoned. 

Describe  incised  wounds. 

Cause.  Sharp  cutting  instruments.  They  bleed  freely^  gape 
widely,  and  cause  burning  pain. 

Treatment.  Use  all  antiseptic  precautions.  Check  hemorrhage 
by  cold,  forcipressure,  and  ligation.  Bring  the  surface  and  edges 
of  the  wound  in  most  accurate  apposition.  If  tendons,  nerves, 
muscles,  or  bones  are  severed,  their  corresponding  ends  must  be 
carefully  united  by  catgut  sutures.  If  the  wound  is  extensive, 
catgut  drains  may  be  employed.  Absolute  rest  must  be  enforced. 
Union,  in  seven  to  ten  days,  by  first  intention 

Describe  lacerated  and  contused  wounds. 

Caused  by  machinery,  dog-bites,  blows  with  blunt  instrument, 
etc. 

CJiaracterized  by  slight  hemorrhage,  moderate  gaping,  dull 
pain,  ecchymosis  (hemorrhage  into  the  surrounding  tissue),  and 
shock. 

Treatment.  Antiseptic.  Thoroughly  cleanse,  remove  dead  tis- 
sue, provide  for  free  drainage,  making  counter  openings  in  depend- 
ent positions,  and  using  full-sized  rubber  drainage-tubes.  Care- 
fully coapt,  if  it  can  be  done  without  tension.  Apply  iodoform 
gauze  liberally,  bichloride  gauze,  bichloride  cotton,  and  band- 
ages.    Keep  the  part  absolutely  at  rest. 

Dangerous  complications.  Shock,  extensive  inflammation  and 
sloughing,  secondary  hemorrhage,  cellulitis,  gangrene,  tetanus. 

Describe  punctured  wounds. 

Caused  by  pointed  instruments  ;  depth  is  their  greatest  meas- 
urement.    Usually  associated  with  contusion. 

Dangers.  Wounds  of  deep  structures,  hemorrhage,  the  car- 
rying in  of  septic  substances,  retention  of  discharge. 

Treatment.  Kemove  the  vulnerating  body,  check  bleeding, 
thoroughly  disinfect  the  accessible  portion  of  the  wound,  put  in 
a  drainage-tube,  apply  an  antiseptic  dressing,  and  put  the  part 
at  rest.     On  the  first  sign  of  inflammation  (pain  and  f3vcr)  re- 


70  ESSENTIALS    OF    SURGERY. 

move  tlie  dressings,  and  lay  the  wound  open  to  its  very  bottom ; 
disinfect,  drain,  and  reapply  the  antiseptic  dressing. 

Describe  gunshot  wounds. 

Caused  by  missiles,  either  round  (buck-shot,  bird-shot)  or  coni- 
cal (pistol  and  rifle  balls).  The  wound  of  entrance  is  smaller 
than  the  wound  of  exit,  and  is  slower  in  healing.  One  bullet 
may  cause  multiple  wounds,  depending  upon  the  position  of 
the  wounded  man  and  the  direction  from  which  the  missile 
comes.  Two  bullets  may  form  but  one  wound  of  entrance.  One 
bullet  may  form  several  wounds  of  exit  by  being  split  in  the 
body  ;  the  wound  of  entrance  may  also  be  the  wound  of  exit, 
as,  when  a  ball  passes  completely  around  the  head,  beneath  the 
skin. 

Balls  may  be  deflected  by  tendons,  bones,  or  even  bloodves- 
sels. Devitalization  of  tissue  is  proportionate  to  the  velocity  of 
the  ball ;  hence  is  greatest  at  the  wound  of  entrance. 

The  immediate  effect  of  gunshot  wounds  is  hemorrhage,  pain,  and 
shoch.  There  may  be  no  pain  ;  excessive  hemorrhage  occurs 
only  when  large  vessels  have  been  wounded  ;  shock  may  be  de- 
layed. 

The  secondary  effect  of  gunshot  wounds  is  inflammation,  slough- 
ing, hemorrhage,  with  the  complications  incident  to  contused 
and  lacerated  wounds  (tetanus,  gangrene,  cellulitis,  and  blood 
poison). 

How  do  you  treat  gunshot  wounds  ? 

On  the  field.  Chech  hemorrhage  by  position,  pressure,  or  the 
tourniquet.  Apply  an  antiseptic  pad  to  the  surface  wounds.  Im- 
mobilize. If  no  septic  matter  has  been  carried  in  by  the  missile, 
or  the  surgeon^ s  probe  or  finger,  the  wound  is  practicall}'^  rendered 
subcutaneous  by  this  treatment,  and  can  be  allowed  to  heal  as 
such,  no  eftbrt  being  made  to  find  the  ball. 

In  the  hospital.  Under  all  antiseptic  precautions,  remove  the 
antiseptic  pad,  thoroughly  clean  the  opening  of  the  wound  and 
the  skin  surface  about  it.  Reapply  an  antiseptic  dressing  and 
immobilize.  Do  not  j)robe.  If  inflammatory  fever  appears,  or 
if  the  original  wound  was  so  extensive  as  to  preclude  the  idea 


WOUNDS.  71 

of  primary  occlusion,  do  a  formal  antisexMc  operation.  Freely  lay 
open  the  wound  tract,  remove  foreign  bodies,  devitalized  tissues, 
or  loose  fragments  of  bone,  explore  and  irrigate  every  recess  of 
the  wound,  pack  with  iodoform  gauze,  insert  sutures  for  the 
purpose  of  approximating  the  parts,  but  do  not  tie  them,  dress 
antiseptically.  In  one  or  two  days  remove  the  dressing  and 
iodoform  packing.  If  the  wound  is  aseptic,  close  by  knotting  the 
sutures.  If  the  wound  is  not  aseptic,  irrigate  and  renew  the 
packing,  or  supply  free  drainage,  dressing  daily  till  the  granula- 
tions become  healthy. 

An  aseptic  bullet  is  readily  encysted.  Should  it  subsequently 
give  trouble,  its  removal  is  much  safer  after  the  wound  has 
healed.  If  the  surgeon  decides  to  search  for  the  bullet  and  ex- 
tract it,  he  must  proceed  as  in  a  formal  operation. 

Nelaton^s  probe,  tipped  with  unglazed  porcelain  which  is 
marked  by  contact  with  lead,  and  long-bladed  bullet  forceps,  may 
be  useful  in  locating  and  extracting  a  bullet. 

What  gunshot  wounds  require  amputation  ? 

1.  Wounds  which  comminute  the  bone  and  injure  or  destroy 
the  main  vessels  of  a  limb. 

2.  Wounds  which  destroy  a  large  portion  of  the  limb,  or  carry 
away  a  part  of  it. 

3.  Wounds  compUcated  by  osteomyelitis,  intractable  secon- 
dary hemorrhage,  or  spreading  gangrene. 

What  injuries  are  classed  as  poisoned  wounds  ? 

1.  Dissecting  wounds.  2.  Stings  of  insects.  3.  Wounds  in- 
flicted by  arachnids  and  reptiles.  4.  Wounds  infected  from 
diseased  animals. 

Describe  the  dissecting  wound. 

It  appears  more  frequently  where  fresh  bodies  or  arsenical 
injections  are  dissected.  It  is  due  to  inoculation  with  infective 
micro-organisms  ;  these  are  destroyed  by  advanced  putrefaction, 
hence  the  most  offensive  bodies  may  be  the  least  dangerous.  Its 
virulence  depends  upon  the  strength  of  the  original  virus  and 
the  constitutional  vigor  of  the  patient  infected. 

SympAoms.     Within  twenty-four  hours  of  the  infliction  of  a 


72  ESSENTIALS    OF    SURGERY. 

scratch  or  cut,  there  is  an  itching,  then  a  burning  pain ;  a  vesicle  is 
formed  which  breaks,  disclosing  an  indurated  ulcer.  There  may 
be  a  stop  at  this  stage,  or  the  inflammation  may  extend  ;  the 
lymphatic  vessel  and  axillary  glands  become  involved,  and  may 
suppurate  freely.  The  constitutional  symptoms  are  well  marked. 
The  patient  may  reach  this  stage  and  rapidly  recover,  or  the 
disease  may  make  steady  progress,  suppuration  attacking  the 
neck  and  thorax,  cellulitis  involving  the  arm,  the  symptoms  be- 
coming markedly  adynamic,  and  the  patient  perishing  of  septi- 
caemia or  pysemia. 

How  do  you  treat  dissecting  wounds  ? 

Immediately,  at  the  time  of  infliction,  encourage  bleeding  by 
tying  a  ligature  about  the  part.  Suck  the  wound  and  press  the 
blood  from  it ;  apply  carbolic  acid  or  sulphate  of  zinc,  dust  with 
iodoform,  and  cover  with  a  light  antiseptic  dressing. 

If  an  infective  inflammation  appears,  freely  incise,  curette  the 
indurated  tissue,  pack  with  iodoform  gauze  and  dress  antisepti- 
cally,  applying  a  splint.  Open  abscesses  promptly.  Make  mul- 
tiple incisions  for  cellulitis. 

Clear  the  bowels,  give  stimulants,  tonics,  and  nutritious  diet. 

For  pain,  apply  locally,  chloral  gr.  xx.  to  the  ounce  of  water. 

A  circular  blister  about  the  arm  may  limit  the  extension  of 
lymphangitis. 

There  is  always  marked  constitutional  involvement  in  these 
wounds.  There  is  fever  and  exhaustion,  loss  of  sleep  from  pain, 
and  the  rapid  development  of  an  adynamic  condition.  Treat 
by  anodynes,  stimulants,  full  diet,  tonics. 

(For  Anthrax,  Glanders,  Hydrophobia,  see  pp.  54,  55.) 

How  do  you  treat  stings  of  insects  and  spider  bites  ? 

Locally.  Ammonia. 

Systemically.  Stimulants  if  necessary,  ammonia  or  brandy. 

What  are  the  symptoms  of  rattlesnake  poisoning  ? 

Kapid  and  extensive  swelling,  discoloration,  and  disintegra- 
tion.    Profound  systemic  depression. 

How  do  you  treat  rattlesnake  bites  ? 

1.  Put  a  tight  ligature  about  the  part  aboye  the  woun^, 


WOUNDS.  73 

2.  Excise,  and  subsequently  cauterize  the  wound  area. 

3.  Encourage  bleeding  by  suction. 

4.  Administer  alcohol  to  the  point  of  intoxication. 

5.  Release  the  ligature  for  a  few  seconds  at  a  time,  tightening 
again  till  each  small  dose  of  poison  thus  admitted  to  the  system 
is  eliminated.     This  is  termed  the  intermittent  ligature. 

Injections  of  permanganate  of  potassium  in  and  about  the 
wound  (10  per  cent.)  are  said  to  be  efficient.  If  collapse 
threatens,  ammonia  must  be  given  hypodermically. 

Wounds  of  Arteries. 

Describe  wounds  of  the  arteries. 

1.  is'on-penetrating.  The  outer  coat  or  coats  only  are  in- 
volved. The  artery  may  subsequently  ulcerate  and  give  way, 
causing  extravasation,  or  may  cicatrize  and  gradually  jield, 
forming  true  circumscribed  traumatic  aneurism. 

2.  Penetrating.  The  artery  is  laid  open.  It  may  be  partially 
cut  across,  when  there  will  be  free  and  continuous  bleeding,  or 
completely  cut  across,  when  contraction  and  retraction  favor  co- 
agulation. 

How  do  you  treat  wounded  arteries  ? 

Ligation  in  the  case  of  large  and  accessible  arteries ;  forcipres- 
sure,  acupressure,  or  the  actual  cautery  under  other  circum- 
stances. When  the  artery  is  partially  divided,  complete  the 
division. 

What  rules  must  be  observed  in  applying  the  ligature  to  a 
wounded  artery  ? 

Tie  in  the  wound.  Tie  both  ends  of  the  wounded  vessel.  Do  not 
search  for  the  arterial  wound  unless  there  is  actual  bleeding  at  the 
time  of  search.  While  operating,  check  further  bleeding  by 
pressure,  or  by  the  finger  in  the  wound. 

How  do  you  treat  gangrene  appearing  after  ligation  of  a 
wounded  artery  ? 
If  rapidly  progressive,  amputate  at  once.    If  slow  in  progress, 
wait  for  the  line  of  demarcation. 


74  ESSENTIALS    OF    SURGERY. 

Describe  traumatic  aneurisms. 

1.  Diffuse  traumatic  aneurism.  This  is  simply  a  collection  of 
arterial  blood,  in  the  tissues  of  a  part,  which  communicates  with 
the  blood  stream  in  the  interior  of  the  artery,  and  is  limited  by 
peripheral  coagulation. 

2.  Circumscribed  traumatic  aneurism.  This  is  blood  in  the  tis- 
sues, communicating  with  the  arterial  current,  and  provided 
with  a  sac  formed  by  the  condensation  of  the  surrounding  cellu- 
lar tissues.  The  circumscribed  traumatic  aneurism  may  be 
formed  by  a  protrusion  of  the  inner  coat  through  a  laceration 
of  the  outer,  in  which  case  it  is  called  hernial;  or  by  the  yield- 
ing of  a  cicatrix  of  the  arterial  coat,  when  it  is  called  true  circum- 
scribed traumatic  aneurism. 

Sym]:'toms  as  for  aneurism,  except  in  the  case  of  diffuse  trau- 
matic aneurism,  when  a  spreading  tumor,  in  which  thrill  and 
bruit  can  be  detected,  and  feeble  or  absent  circulation  of  the 
part  below,  will  indicate  the  nature  of  the  affection. 

How  do  you  treat  traumatic  aneurism  ? 

Ligate  just  above,  or,  if  the  aneurism  threatens  to  burst,  open 
the  sac  and  tie  above  and  below. 

Describe  an  arterio-venous  aneurism. 

Definition.  An  abnormal  communication  between  an  artery 
and  a  vein. 

Cause.     A  wound  involving  both  vessels. 

Varieties :  1.  Aneurismal  varix.  The  artery  and  vein  commu- 
nicate directly.  The  vein  is  dilated  by  the  arterial  beat,  form- 
ing a  fusiform  swelling. 

2.  Varicose  aneurism.  The  artery  and  vein  communicate  by 
means  of  an  intermediate  sac. 

Symptoms.  A  tumor,  characterized  by  a  jarring  pulse,  and  a 
rough  buzzing  bruit.  The  artery  is  large  above  and  small  be- 
low.    The  vein  is  large  above  and  pulsates. 

Treatment.  Pressure  on  the  tumor  by  means  of  an  elastic 
bandage.  Ligation  of  the  artery  above  and  below.  When  pres- 
sure fails  to  control  the  bleeding  from  the  vein,  it  must  be  liga- 
tured also. 


WOUNDS.  75 

What  are  the  dangers  in  wounds  of  veins  ? 

1.  Hemorrhage.     Control  by  pressure  or  ligation. 

2.  Blood  x>oisoning  from  septic  thrombosis.  Prevent  by  keep- 
ing the  wound  aseptic. 

3.  E^nirance  of  air.  Characterized  by  a  hissing  sound  during 
inspiration,  by  the  escape  of  frothy  blood  during  expiration,  by 
a  churning  sound  heard  on  ausculting  the  heart,  and  by  prompt 
collapse  of  the  patient.  Stop  the  vein  wound  immediatel}-  with 
the  finger,  or  fill  the  entire  wound  with  water.  Ether,  brandy, 
or  ammonia  subcutaneously. 


Wounds  of  Nerves. 

What  are  the  consequences  of  wounded  nerves  ? 

The  nerve  may  be  partially  or  completely  divided.  If  com- 
pletely divided,  the  entire  peripheral  part  undergoes  atrophy 
and  degeneration  (Wallerian  degeneration),  the  proximate  end 
becomes  bulbous  from  proliferation  of  the  fibrous  tissue.  Should 
union  occur  the  degenerated  fibres  are  regenerated. 

As  a  result  of  destroyed  innervation  there  follows  : — 

1.  Motor  and  sensory  paralysis. 

2.  Muscular  atrophy  and  degeneration. 

3.  Trophic  changes,  characterized  by  the  skin  becoming  glazed, 
smooth,  bluish-red,  and  prone  to  ulcerate  ;  the  nails  becoming 
cracked  and  deformed  ;  the  hair  falling  out  ;  and  rheumatoid 
joint  affection. 

How  do  you  treat  wounded  nerves  ? 

If  recent.^  suture  together  with  fine  chromicized  catgut  passed 
through  the  sheath  of  the  nerve.  If  old,  free  from  all  cicatricial 
adhesions,  resect  the  bulbous  proximal  extremity,  freshen  the 
distal  extremity,  and  suture  as  before. 


Head  Injuries. 

Give  the  surgical  anatomy  of  the  scalp. 

Lai/er.s.     Skin,  superficial  fascia,  aponeurosis  of  the  occipito- 
frontalis,  subaponeurotic  fascia,  pericranium. 


76  ESSENTIALS    OF    SURGERY. 

Superficial  fascia  binds  the  skin  firmly  to  the  aponeurosis.  It 
is  made  up  of  intersecting,  non-elastic  bands  of  connective 
tissue,  containing  in  its  meshes  globules  of  fat ;  it  is  very  vas- 
cular, and  freely  supplied  with  nerves. 

Fig.  5. 


Layers  of  the  scalp. 

Aponeurosis,  Covers  the  vault  of  the  skull,  is  attached  to 
the  superior  curved  line  and  the  mastoid  process  ;  is  blended  in 
front  with  the  pyramidalis  nasi,  corrugator  supercilii,  and 
orbicularis  palpebrarum,  and  is  continued  laterally  to  the 
zygoma  by  laminated  layers  of  areolar  tissue. 

Subaponeurotic  fascia.  Is  made  of  delicate,  elastic,  con- 
nective-tissue fibres  containing  no  fat  ;  loose  in  texture,  and 
allowing  free  motion  on  the  part  of  the  aponeurosis.  Blood 
supply  limited. 

Arteries  of  the  scalp  are  from  the  temporal,  occipital,  auricular, 
supraorbital,  and  frontal.  Certain  branches  strike  deep  and 
supply  the  periosteum. 

Veins  of  the  scalp  intercommunicate  with  those  of  the  peri- 
cranium, the  diploe,  the  meninges,  the  sinuses. 

What  is  the  surgical  bearing  of  these  facts  ? 

1.  From  the  vascularity  of  the  superficial  fascia  extensive  in- 
jury can  be  quickly  repaired. 

2.  From  its  lack  of  elasticity  no  tension  can  be  made  in 
uniting  wounds.  There  is  little  gaping  unless  the  aponeurosis 
is  cut. 

3.  From  its  denseness  of  structure,  effusion,  or  suppuration 
will  probably  be  circumscribed,  and  movable  only  to  the  extent 
that  the  aponeurosis  can  be  moved. 

4.  In  the  subaponeurotic  fascia  effusion  or  suppuration  will 


WOUNDS.  77 

probably  not  be  circumscribed,  from  the  looseness  of  structure, 
and.  will  appear  as  a  fluctuating  swelling  about  the  ears  or  the 
root  of  the  nose,  from  which  position  it  can  be  moved  to  the 
various  dependent  parts  of  the  aponeurotic  attachment. 

5.  The  arrangement  of  the  vessels  allows  the  scalp  to  be 
entirely  detached  from  the  pericranium  without  loss  of  vitality. 

6.  It  also  allows  of  the  direct  extension  of  septic  processes 
into  the  diploe  and  the  interior  of  the  skull. 

7.  Swellings  beneath  the  pericranium  are  bounded  by  the 
sutures  and  are  immovable. 

Describe  contusion  of  the  scalp. 

Swelling  very  rapid.  On  palpation  a  soft  yielding  centre  (fluid 
blood),  and  hard,  distinctly  outlined  edges  (fat  and  coagulum). 

How  do  you  diagnose  contusion  from  depressed  fracture  ? 

The  hard  margins  about  the  apparently  depressed  central 
area  are  raised  from  the  hone.  By  firm  pressure  with  the  nail 
the  clot  may  be  pushed  aside,  and  the  bone  felt  through  it. 

In  case  of  fracture,  the  finger  passes  directly  from  the  surf  ace 
of  the  skull  into  a  depression,  without  first  surmounting  a  ridge. 

Where  may  the  effusion  due  to  contusion  take  place  ? 

The  blood  may  be  effused  in  the  superficial  fascia,  beneath  the 
aponeurosis  and  beneath  the  pericranium.  When  in  the  latter 
position  it  may  ossify. 

How  do  you  treat  contusions  of  the  scalp? 

Ice-bag  till  swelling  ceases  to  increase.  Evaporating  and 
stimulating  lotions,  moderate  pressure.  Aspirate  a  persistent 
hsematoma.     If  suppuration  occurs,  incise  freely. 

How  do  you  treat  wounds  of  the  scalp  ? 

Carefully  shave,  wash,  and  disinfect  the  region  of  the  wound. 
Remove  all  foreign  matter,  and  check  hemorrhage.  If  the  wound 
is  very  extensive,  drain  by  strands  of  horsehair  or  catgut.  Su- 
ture, making  accurate  apposition,  apply  iodoform,  protective, 
wet  bichloride  gauze,  dry  bichloride  gauze,  bichloride  cotton,  and 
a  firm  bandage. 


78  ESSENTIALS    OF    SURGEKY. 

Describe  contusions  of  the  cranial  bones. 

Contusions  may  cause — 

1.  An  inflammation  of  the  pericranium,  or  periostitis,  which 
may  terminate  in  resolution^  chronic  periostitis^  or  suppuration^ 
involving  the  neighboring  bone,  and  terminating  in  caries  or  ne- 
crosis. 

2.  The  inflammation  may  extend  to  the  diploe,  causing  septic 
osteophlebitis,  with  septicaemia  or  pyaemia. 

3.  The  inflammation  may  extend  to  the  intracranial  struc- 
tures, causing  supra-  or  subdural  suppuration. 

4.  The  inflammation  may  terminate  in  chronic  osteitis  and 
pachymeningitis,  causing  thickening. 

"What  symptoms  aid  the  surgeon  in  determining  the  character 
and  seat  of  inflammatory  action  ? 

1.  Pus  beneath  the  xjericraniiim,  or  simple  necrosis.  Chill  and 
fever,  moderate  in  severity,  local  oedema,  tenderness,  and  deep 
fluctuation.  Detection  of  the  diseased  bone  when  the  abscess  is 
opened. 

2.  Pus  in  the  diploe.  Chilly  high  fever,  local  signs  of  suppura- 
tion, general  symptoms  of  pyaemia  or  septicaemia. 

Intracranial  extension.  High  fever,  headache,  vomiting,  mono- 
plegia or  hemiplegia,  delirium  or  stupor. 

PotVs  puffy  tumor,  a  circumscribed  superficial  swelling  over 
the  affected  area,  sometimes  accompanies  supradural  suppura- 
tion. 

How  do  you  treat  contusions  of  the  cranial  bones  ? 

Open  tlie  bowels  freely,  keep  the  patient  in  bed  and  absolutely 
quiet,  give  liquid  diet,  and  apply  cold  to  the  head.  If  there  is  a 
wound,  rigid  antisepsis  must  be  observed.  Should  symptoms 
point  to  subpericranial  suppuration,  open  freely.  Deeper  suppu- 
ration should  at  once  be  exposed  by  the  trephine. 

Classify  fractures  of  the  skull. 
A.  Fractures  of  the  vault.     B.  Fractures  of  the  base. 

1.  Partial.,  involving  the  inner  or  the  outer  table. 

2.  Complete.,  involving  the  entire  thickness  of  the  skull.  The 
inner  table  is  usually  damaged  more  extensively  than  the  outer. 


WOUNDS.  79 

Of  the  complete  fractures  we  have — 

1.  Fissured^  taking  the  form  of  a  simple  crack. 

2.  Stellate  or  radiate,  appearing  as  several  fissures  radiating  iif 
different  directions. 

3.  Comminuted.     The  bone  is  broken  into  several  pieces. 

4.  Depressed.    The  bone  is  pressed  in  upon  the  brain. 

5.  Punctured  ov  pierced.  This  is  usually  accompanied  by  con- 
siderable comminution  of  the  inner  table. 

Any  of  these  fractures  may  be  simpjle  (no  external  wound)  or 
compound  (external  wound  communicating  with  the  break). 

What  causes  fractures  of  the  vault  of  the  skull  ? 

Sudden  concentrated  force,  as  the  blow  of  a  hammer. 

How  do  you  diagnose  fractures  of  the  vault  of  the  skull  ? 

Simple  fractures  without  displacement  (fissured,  stellate)  can 
only  be  inferred  from  accompanying  symptoms. 

Simple  fractures  with  displacement  can  frequently,  but  not  al- 
ways, be  detected  by  careful  examination  of  the  surface.  There 
is  usually  depression,  and  the  abrupt  bone  edges  may  be  felt. 
Symptoms  of  compression  are  commonly  present. 

Compound  fractures  can  be  diagnosed  by  inspection  and  palpa- 
tion through  the  wound.  There  is  frequently  free  bleeding,  and 
there  may  be  escape  of  cerebrospinal  fluid. 

How  do  you  treat  fractures  of  the  vault  ? 

Simple  or  compound  fracture,  without  depression. 

Place  the  patient  in  a  quiet,  darkened  room,  clear  the  bowels 
with  calomel,  shave  the  head,  and  apply  an  ice-bag ;  give  a  light 
milk  diet  (Oij  daily).  If  the  wound  is  compound,  treat  antisep- 
tically. 

Calomel  gr.  ^,  Dover's  powder  gr.  ij,  every  two  hours,  is 
sometimes  kept  up  for  three  or  four  weeks. 

Simjjle  depjressed  fractures  without  signs  of  compjression  treat  as 
above  unless  symptoms  arise. 

Compound  depressed  fractures,  and  punctured  fractures.  Always 
elevate,  trephining  if  necessary.  Thorough  asepsis  makes  the 
operation  entirely  safe.  Punctures  through  the  supraorbital 
plate  or  the   nose  do  not  in  themselves  indicate  trephining, 


80  ESSENTIALS    OF    SURGERY. 

though  the  operation  should  he  done  if  unfavorable  symptoms 
subsequently  appear. 

What  is  the  cause  of  fractures  at  the  base  of  the  skull  ? 

Direct  f (free.  Punctures.  Driving  of  a  condyle  through  the 
glenoid  fossa  by  a  blow  upon  the  chin,  or  shattering  the  cribri- 
form plate  of  the  ethmoid  by  a  blow  on  the  nose. 

Indirect  force.  1.  Falls  iqwn  the  buttocks  or  feet  drive  the  si)ine 
against  the  occipital  condyles. 

2.  Falls  upon  the  cranial  vault  drive  the  occipital  condyles 
against  the  spine.  If  the  head  is  flexed  the  force  is  carried  back- 
ward, and  is  exerted  on  the  posterior  cerebral  fossa.  If  the  head 
is  extended,  the  force  is  carried  forward,  and  is  exerted  on  the 
anterior  or  middle  cerebral  fossa. 

3.  Conduction  and  amplification  of  vibrations.  The  force  is 
powerful  and  diffused.  If  applied  to  the  frontal  region.,  there  is 
usually  fracture  of  the  anterior  cerebral  fossa.  The  middle 
cerehral  fossa  is  fractured  by  such  force  applied  to  the  temporo- 
pjarietal  region.  The  x^osterior  cerebral  fossa  by  force  applied  to 
the  occipital  region. 

What  are  the  symptoms  of  fracture  of  the  anterior  cerebral 
1 


Free  and  continuous  bleeding  from  the  nose.  Subconjunctival 
effusion  with  palpebral  ecchymosis,  involving  the  lower  eyelid 
particularly.  Escape  of  watery  fluid  (cerebro-spinal  fluid)  from 
the  nose.  Paralysis  of  the  olfactory,  optic,  or  oculo-motor 
nerves.     Concussion  or  compression. 

The  blood  and  cerebro-spinal  fluid  may  pass  back  into  the 
pharynx,  which  should  always  be  examined  in  these  injuries. 

What  symptoms  denote  fracture  of  the  middle  cerebral  fossa  ? 

Free  continued  bleeding  from  the  ear,  followed  by  escape  of 
cerebro-spinal  fluid,  increased  in  quantity  by  firm  pressure  on 
the  jugular  veins. 

Paralysis  of  the  auditory  and  facial  nerves,  usually  coming  on 
some  days  after  the  injury.  If  the  membrana  tympani  is  not 
ruptured,  the  blood  and  cerebro-spinal  fluid  will  escape  into  the 
pharynx  by  way  of  the  Eustachian  tube. 


WOUNDS.  81 

What  symptoms  characterize  fractures  of  the  posterior  cerebral 
fossa  ? 

Examination  through  the  pharynx  may  show  depression  or 
comminution.  Severe  pharyngeal  hemorrhage.  Ecchymosis  of 
the  lateral  regions  of  the  neck. 

When  the  neck  is  not  involved  in  the  injury  late  discoloration 
is  a  valuable  sign  of  fracture  at  the  base  (middle  or  posterior 
fossa). 

How  do  you  treat  fractures  of  the  base? 

Since  these  fractures  are  usually  fissured,  they,  in  themselves, 
rarely  require  treatment.  The  gravity  of  fractures  of  the  base 
depends  almost  entirely  upon  the  concomitant  injury  to  the 
brain  or  its  bloodvessels,  and  the  treatment  must  be  directed  to 
the  prevention  of  encephalitis  which  is  liable  to  develop  after 
these  injuries. 

Keep  the  patient  absolutely  quiet.  Elevate  the  head  and  ap- 
ply an  ice-bag  to  it.  Control  restlessness  b}^  bromide  of  potas- 
sium or  morphia.  Give  water  only,  for  48  hours,  then  a  light 
liquid  diet.     Mercurials  may  be  used. 

When  the  cerebro-spinal  fluid  escapes  externally,  the  fracture 
is,  of  course,  compound,  and  the  channel  of  escape  must,  if  pos- 
sible, be  antiseptically  cleansed  and  occluded. 


Injuries  of  the  Meninges  and  Brain. 

In  what  regions  may  intracranial  blood  extravasations  take 
place  ? 

1.  Between  the  dura  mater  and  the  skull. 

2.  In  the  cavity  of  the  arachnoid. 

3.  In  the  meshes  of  the  pia  mater  (on  the  brain  surface). 

4.  In  the  cerebral  substance. 
.5.  In  the  ventricles. 

What  are  the  sources  of  extravasation  between  the  dura  mater 
and  the  skull  ? 
1.  Tlie  small  vessels  passing  from  the  dura  to  the  bone.     The 
hemorrhage  is  slight  in  amount. 
6 


82  ESSENTIALS    OF    SURGERY. 

2.  The  middle  meningeal  artery.  The  usual  source  of  exten- 
sive bleeding. 

3.  The  venous  sinuses.     Rarely  a  source  of  bleeding. 

What  symptoms  denote  extravasation  of  blood  between  the  dura 
mater  and  the  skull  ? 

Symptoms  of  compression  coming  on  after  an  interval  of  im- 
munity. 

Immediately  after  an  injury  the  patient  suffers  from  concussion 
and  shock ;  he  reacts  and  recovers  from  this  condition  shortly  to 
exhibit  symptoms  of  compression^  characterized  by :  1.  Spasm 
followed  by  paralysis,  affecting  the  face,  arm,  or  one  side  of  the 
body,  and  accompanied  by  a  local  fall  of  temperature.  2. 
Coma.     3.  Widely  dilated  pupil  of  the  affected  side. 

How  do  you  treat  hemorrhage  between  the  dura  and  the  skull  ? 

Trephine  over  the  middle  meningeal  artery  (anterior  branch). 
The  pin  of  the  trephine  is  placed  1^  inches  behind  the  external 
angular  process  of  the  frontal  bone,  and  the  same  distance  above 
the  most  prominent  part  of  the  zygoma.  Clear  away  the  clot, 
close  the  artery  by  means  of  ligatures,  a  plug  of  wax  or  catgut, 
or  the  touch  of  a  hot  needle.  If  the  trephine  opening  does  not 
expose  the  bleeding  point,  remove  the  bone  along  the  course  of 
the  artery  till  the  source  of  hemorrhage  is  found. 

If  no  supradural  hemorrhage  is  found,  but  the  dura  is  bluish, 
projecting,  and  does  not  pulsate,  there  is  effusion  beneath,  which 
must  be  evacuated  by  incision. 

If  the  symptoms  do  not  definitely  indicate  the  probable  seat 
and  nature  of  the  injury,  treat  as  for  all  head  injuries,  i.  e.,  elevate 
the  head,  and  apply  cold  to  it,  clear  the  bowels,  give  a  very 
restricted  fluid  diet,  use  bromides,  chloral,  morphia,  mercury, 
or  bleeding  as  indicated  by  symptoms. 

What  are  the  symptoms  of  hemorrhage  beneath  the  dura  ? 

Blood  in  the  arachnoid  is  generally  diffused  over  the  whole 
cerebral  hemisphere.  There  may  be  symptoms  of  compression, 
or,  some  time  after  the  injury,  irritability  of  temper,  headache, 
or  convulsions  may  develop.     There  is  nothing  diagnostic.     The 


WOUNDS.  83 

effused  blood  may  become  encysted  or  may  organize  as  a  tough 
membrane. 

Blood  in  the  pia  mater  usually  accompanied  by  cerebral  lacera- 
tion. The  blood  is  widely  diffused.  The  symptoms  are  those 
of  the  brain  injury,  or  of  apoplexy. 

How  do  you  treat  subdural  extravasations  ? 

Expectantly,  as  for  head  injuries  in  general.  If  the  symptoms 
should  point  to  localization  of  the  hemorrhage,  trephine. 

Concussion  and  Contusion. 

Describe  concussion  of  the  brain. 

By  concussion  is  meant  a  simple  jarring  of  the  brain  without 
attendant  lesions.  There  is,  however,  always  congestion,  and, 
commonly,  serous  or  sanguinolent  effusion.  If  concussion  is  at- 
tended with  marked  and  persistent  symptoms,  it  is  probably 
associated  with  contusion. 

Contusion  may  be  circumscribed  or  diffused.  It  may  produce 
hemorrhage  in  mass,  or  diffuse  miliary  extravasations.  Its  effects 
may  be  found  at  the  point  of  injury,  or  on  the  opposite  portion 
of  the  brain.  Laceration  frequently  accompanies  contusion. 
The  anterior  part  of  the  frontal  and  temporo-sphenoidal  lobes 
are  commonly  involved. 

What  are  the  symptoms  of  concussion  ? 

Of  the  sUg  liter  form,  momentary  loss  of  consciousness,  or  giddi- 
ness, with  pale  face  and  feeble  pulse,  some  mental  confusion, 
sweating  of  the  face,  nausea,  vomiting,  and  reaction. 

Of  the  more  severe  forms  (contusion,  with  congestion,  bleeding 
or  laceration),  prolonged  unconsciousness,  with  feeble,  scarcely 
perceptible  pulse,  shallow  breathing,  pale,  cold  surface,  subnor- 
mal temperature,  muscular  relaxation,  variable  pupils  (depend- 
ent on  the  seat  and  character  of  the  injury).  Restlessness, 
screaming,  and  local  spasm  or  paralysis  may  suggest  lacera- 
tion.    The  heginniny  of  reaction  is  characterized  by  vomiting. 

After  a  variable  time  the  patient  may  pass  into  the  second  stage 
of  concussion^  termed  cerebral  irritation. 


84  ESSENTIALS    OF    SURGERY. 

He  can  be  roused  with  difficulty,  but  responds  angrily,  and  im- 
mediately lapses  into  a  somnolent  condition. 

He  lies  curled  up  on  his  side,  with  limbs  flexed  and  eyes  tightly 
closed.  He  resents  any  eftbrt  at  changing  his  posture.  He  may 
be  exceedingly  restless. 

The  pulse  is  small  and  feeble,  the  respirations  are  quiet,  or  at 
least  are  not  stertorous.    The  pupils  are  contracted. 

As  the  condition  of  cerebro-irritation  subsides,  the  third  stage 
of  concussion,  characterized  by  inflammation,  abscess,  softening, 
or  fatuity,  may  develop.  Later,  hereditary  or  acquired  tendency 
to  brain  disease  may  appear. 

Concussion  and  contusion  are  always  attended  by  slioct. 

How  do  you  treat  cerebral  concussion  and  contusion  ? 

First  stage  (insensibility  and  shock).  Absolute  quiet  in  a  dark- 
ened room.  If  reaction  is  slow,  encourage  by  external  heat. 
Very  rarely  should  stimulants  be  given  ;  if  absolutely  indicated^ 
administer  brandy  or  ammonia  hypodermically.  On  the  deve- 
lopment of  the  second  stage  (cerebral  irritation)  apply  an  ice-bag 
to  the  raised  head,  clear  the  bowels,  give  water  and  cracked  ice 
for  two  days,  followed  by  milk  and  lime-water,  in  small  quanti- 
ties. For  restlessness  and  pain  give  bromide,  chloral,  or  opium. 
Prevent  sequelae  by  long-continued  rest  in  bed,  by  very  slow  re- 
sumption of  ordinary  duties  and  responsibilities. 

Compression. 

What  are  the  causes  of  cerebral  compression  ? 

1.  Depressed  bone.  2.  Extravasated  blood.  3.  Pus,  or  in- 
flammatory products.     4.  Foreign  bodies.     5.  Tumors. 

What  are  the  symptoms  of  cerebral  compression  ? 

Unconsciousness^  absolute  (coma).  Bes'pirations,  slow,  sterto- 
rous, blowing.  Pidse  full  and  slow.  Paralysis  involving  one 
side  of  the  body.  Pupils  may  be  unequal.  Urine  retained,  faeces 
passed  involuntarily.     Decubitus  dorsal. 

How  do  you  determine  as  to  the  cause  of  compression  ? 

Symptoms  appear  immediately  when  due  to  dejDressed  fracture 


WOUNDS.  "  85 

or  foreign  body  ;  after  some  hours,  if  due  to  hemorrhage  ;  after 
some  days,  if  due  to  iutiammation. 

How  do  you  treat  compression  of  the  brain? 

Trephine  and  remove  the  cause,  if  it  can  be  located.  Under 
other  circumstances  expectantly,  as  for  head  injuries  in  general. 

How  do  you  distinguish  concussion  from  compression  ? 

In  many  cases  this  cannot  be  done  ;  the  symptoms  of  one  con- 
dition merging  into  those  of  the  other.  The  distinctive  symp- 
toms of  the  two  affections  are  as  follows  (Agnew)  : — 

Concussion.  _                Com])ression. 

Patient  semi-conscious ;  special  Absolutely  unconscious,  para- 
senses  blunted,  not  abolished.  lyzed,  and  with  abolition  of  special 

Power  of  movement  not  lost.  senses. 

Kespiration  quiet  and  feeble.  Respiration  full  and  noisy. 

Pulse  feeble,  frequent,  and  inter-  Pulse  full,  slow,  laboring, 
mittent. 

Nausea  and  vomiting.  Neither  nausea  nor  vomiting. 

Pupils  generally  contracted.  Pupils  generally  dilated,  often  un- 
equal. 

Subnormal  temperature.  Temperature  about  normal. 

Of  what  significance  is  the  size  of  the  pupil  in  brain  injuries  ? 

A  contracted  i>upil  denotes  cerebral  irritation  (slight  injuries 
or  effusion).  A  \)\x\){\  fixed  in  wide  dilatation  denotes  abolition  of 
cerebral  function  (large  effusions  or  extensive  injury). 


Intracranial  Inflammation. 

What  are  the  causes  of  traumatic  intracranial  inflammation? 

Wounds  of  the  scalp,  bone,  or  brain.  Fractures  or  contusions  of 
the  cranial  bones.  Concussion^  compression^  contusion^  or  lacera- 
tion of  the  brain. 

Describe  traumatic  intracranial  inflammation. 

There  may  be  either  meninfjitis  or  encephalitis.  More  com- 
monly, both  meninges  and  brain  are  involved  (meningo-encepha- 
litis).  Sliould  suppuration  occur,  the  pus  may  be  diffused,  or  may 
form  an  abscess.     Tlie  inflammation  may  be  acute  or  chronic. 


86  ESSENTIALS    OF    SURGERY. 

Give  the  symptoms  of  traumatic  intracranial  inflammation. 

Pain  referred  to  the  seat  of  injury,  fever ^  intolerance  of  light 
and  sound,  vomiting  with  a  clear  tongue,  contracted  pupils,  quick, 
full  pulse,  restlessness,  insomnia,  and  delirium.  Later,  com- 
pression symptoms  develop,  and  the  patient  perishes  comatose. 
Formation  of  pus  is  attended  by  rigors. 

How  can  you  localize  the  inflammation  ? 

If,»in  from  one  to  four  weeks  from  the  infliction  of  injury, 
symptoms  of  encephalitis  suddenly  develop  preceded  by  head- 
ache, if  Pott's  puffy  tumor  of  the  scalp  forms,  if  there  is  local 
spasm  or  paralysis,  and  the  history  of  a  chill,  there  is  probably 
an  abscess  between  the  dura  and  the  skull. 

Inflammatory  symptoms,  appearing  about  the  fourth  day  after 
a  head  injury,  point  to  contusion  or  laceration  of  the  brain  sub- 
stance. 

If,  after  several  weeks,  there  is  found  optic  neuritis,  with  hebe- 
tude, headache,  and  involvement  of  motor  areas ;  if  there  has 
been  a  chill,  and  symptoms  of  compression  develop  suddenly, 
there  is  probably  a  cerebral  abscess. 

How  do  you  treat  traumatic  meningo-encephalitis  ? 

Prevent  by  quiet,  cold  to  the  head,  purgation,  low  diet,  and 
absolute  asepticity  of  all  head  wound. 

Treat,  on  the  earliest  symptom,  by  calomel,  bleeding  from  ex- 
ternal jugular,  ice-bag  to  head,  light  diet ;  opium  and  bromide 
as  required,  calomel  gr.  ^.  Dover's  powder  gr.  ij  every  two 
hours. 

If  an  abscess  can  be  locahzed,  trephine  and  evacuate. 

Describe  hernia  cerebri. 

Definition.  A  protrusion  of  brain  matter  disintegrated  by  in- 
flammatory action,  through  an  opening  in  the  skull. 

Cause.  Wound  of  the  bone  and  dura  mater,  attended  with 
laceration  and  bruising  of  the  brain  substance. 

Appearance.  A  blood-stained,  fungous  mass,  projecting  from 
the  skull  opening. 

Prognosis.     Usually  bad. 


WOUNDS.  87 

Treatment.  Kemove  all  irritating  causes,  such  as  spicules  of 
bone.    Treat  in  general  as  for  encephalitis. 

Locally,  apply  antiseptic  dressings,  with  very  moderate  com- 
pression. Nature  sometimes  effects  a  cure  by  strangulating  the 
growth. 

What  are  the  prog^nosis  and  treatment  of  foreign  bodies  in  the 
brain  ? 

The  ultimate  prognosis  is  bad  in  all  cases  where  the  foreign 
body  is  not  removed.  The  usual  foreign  body  is  a  bullet.  Its 
wound  may  be  perforating  or  'penetrating. 

The  perforating  wound  allows  of  free  drainage,  and  the  foreign 
body  has  passed  out ;  hence,  if  not  intrinsically  fatal,  the  prog- 
nosis is  comparatively  favorable.     Trephine,  if  necessary. 

The  pjenetrating  wound  should  be  trephined  to  remove  bone 
spiculse.  Explore  with  a  soft  rubber  catheter.  The  ball,  being 
found,  should  be  removed,  either  through  the  wound  of  entrance, 
or  by  making  a  counter  trephine  opening.  Provide  abundantly 
for  drainage.    Absolute  asepsis.    Treat  as  for  head  injuries. 

Cerebral  Localization. 

Give  the  position  of  the  motor  areas  grouped  about  the  fissure 
of  Rolando. 

1.  The  face.  Motor  and  sensory  nerves  from  lower  third  of 
the  ascending  frontal  and  parietal  convolutions,  and  posterior 
end  of  the  second  frontal  convolutions. 

2.  The  arm.  Motor  and  sensory  suppl}-  from  middle  third  of 
ascending  frontal  and  parietal  convolutions. 

3.  The  leg.  Motor  and  sensory  supply  from  the  upper  portion 
of  the  ascending  frontal  and  parietal  convolutions,  and  the 
paracentral  lobule. 

4.  The  tongue.  Receives  its  nerve  supply  from  the  posterior 
portion  of  the  third  (inferior  frontal)  convolution  of  the  left  side 
in  right-handed  persons. 

Local  spasm  and  hypcr£esthesia  indicate  an  irritative  lesion 
of  a  motor  area. 


88  ESSENTIALS    OF    SURGERY. 

Local  paralysis  and  anaesthesia  indicate  complete  suppression 
of  function  from  more  extensive  injury. 

What  symptoms  founded  on  cerebral  localization  indicate  tre- 
phining? 

Hemiplegia,  complete  or  incomplete,  with  or  without  hemi- 
spasm, following  a  blow  on  the  temporo-parietal  region,  would 
indicate  an  exploratory  operation  on  the  side  opposite  to  that 
of  peripheral  symptoms. 

Monoplegia  or  monospasr)i  following  an  injury  to  the  head  in- 
dicates operation. 

Mono-liypermstliesia — anaesthesia  or  analgesia  following  an  in- 
jury indicates  an  operation. 

If  the  peripheral  sensory  or  motor  disturbance  be  on  the  side 
opposite  to  that  of  the  lesion,  operate  at  the  site  of  the  lesion  ; 
if,  however,  these  symptoms  are  on  the  same  side,  exploratory 
operation  would  be  indicated  on  the  opposite  side  of  the  head. 

What  symptoms  contraindicate  operation? 

Lesions  of  the  base  of  the  hrain  as  indicated  by  paralysis  of 
cranial  nerves,  neuro-retinitis,  Cheyne-Stokes  respiration. 
Hemiplegia  accompanied  by  anaesthesia. 

How  can  the  position  of  the  Rolandic  fissure  be  indicated  upon 
the  head  ? 

Shave  the  scalp,  draw  a  vertical  line  from  one  external 
auditory  meatus  to  the  other  (at  right  angles  to  the  alveolo-con- 
dyloid  plane),  from  the  centre  of  this  vertical  line  (bregma) 
measure  directly  backward  for  5.5  centimetres  (5  in  women). 
From  the  external  angular  process  of  the  frontal  bone  measure 
7  centimetres  horizontally  backward  and  3  centimetres  vertically 
upward  ;  a  line  drawn  from  this  point  to  the  point  5.5  centi- 
metres posterior  to  the  bregma  will  indicate  the  fissure  of 
Rolando.  For  general  hemiplegia  trephine  over  the  centre  of 
the  line.     In  other  cases  over  the  portion  chiefly  involved. 

Sensory  disturbances  of  the  arm  or  leg  would  indicate  that 
the  lesion  lies  somewhat  posterior  to  the  fissure  of  Rolando. 


WOUNDS.  89 

What  are  the  indications  for  trephining  ? 

1.  Simple  depressed  fractures,  attended  with  persistent  grave 
symptoms. 

2.  Compound  depressed  fractures.  Except  in  children,  when 
the  depression  is  of  less  serious  consequence  and  often  spon- 
taneously corrected. 

3.  Punctured  fractures. 

4.  The  presence  of  a  foreign  body. 

5.  Traumatic  osteomyelitis  and  necrosis. 

6.  Localized  blood  clot  between  the  dura  mater  and  the  bone. 

7.  Localized  intracranial  suppuration,  with  symptoms  of  com- 
pression or  irritation. 

8.  Traumatic  epilepsy  or  localized  obstinate  headache  follow- 
ing an  injury. 

9.  Accessible  cerebral  tumors. 

Many  surgeons  advise  trephining  in  all  depressed  fractures^ 
with  or  without  serious  symptoms. 

Describe  the  operation  of  trephining. 

Prepare  the  patient  the  day  before  the  operation,  if  possible, 
by  shaving  the  scalp  and  washing  with  sublimate  soap  and  warm 
water,  followed  by  a  cleansing  with  ether,  after  which  washings 
with  the  sublimate  soap  and  water  must  again  be  repeated. 
Apply,  for  twenty-four  hours,  to  the  entire  scalp,  gauze  saturated 
in  1:2000  bichloride  solution,  covered  in  with  an  antiseptic 
dressing.  Renew  the  sublimate  and  ether  washings  just  before 
the  operation,  and  further  cleanse  the  surface  with  1 :  500  bi- 
chloride solution. 

The  instruments  required  are  scalpel,  haemostatic  forceps, 
periosteal  elevators,  a  conical  trephine,  a  fine  probe,  a  small  stiff 
brush,  a  Hey's  saw,  bone  forceps,  curved  needles,  and  catgut. 

The  incision.  Must  he  free  and  to  the  bone^  including  perios- 
teum. A  semicircular  flap  is  raised,  the  pin  of  the  trephine  is 
pressed  to  the  bone,  and,  by  a  twisting  motion,  made  to  penetrate 
till  the  teeth  grip,  when  the  pin  is  withdrawn,  and  the  instru- 
ment steadily  worked  through.  Free  bleeding  indicates  when  the 
diploe  is  reached.  (Note  that  in  infancy  and  old  age  there  is 
practically  no  diploe.)     The  instrument  must  now  be  advanced 


90  ESSENTIALS    OF    SURGERY. 

with  the  greatest  care.  It  is  removed  from  time  to  time,  and  the 
groove  probed  to  see  whether  the  inner  tablet  is  penetrated  at 
any  part.  When  the  bone  is  loosened,  it  is  removed  by  means 
of  sequestrum  forceps  or  an  elevator,  and  wrapped  in  a  warm 
antiseptic  towel.  The  surgeon  now  endeavors  to  accomplish 
the  specific  object  for  which  the  skull  was  opened.  Spiculse  of 
bone  are  removed,  depressed  fractures  are  elevated,  bleeding 
meningeal  arteries  are  secured  by  passing  a  thread  beneath  them, 
clots  are  cleared  away.  If  farther  exposure  is  necessary,  it  can 
be  accomplished  by  dividing  the  bone  by  a  chisel,  bone  forceps, 
or,  best  of  all,  a  circular  saw  run  by  a  surgical  engine.  On  the 
completion  of  the  operation  free  drainage  is  provided  for  by 
means  of  catgut  strands,  the  disk  of  bone  is  replaced,  either  entire 
or  cut  into  pieces,  the  flap  is  held  in  place  by  one  or  two  sutures. 
Iodoform  is  dusted  over  the  line  of  incision,  a  deep  dressing  of 
iodoform  gauze  is  applied  over  and  about  the  wound,  and  the 
dressing  completed  by  bichloride  gauze,  bichloride  cotton,  and 
an  elastic  bichloride  bandage. 


Wounds  of  the  Face. 

What  rules  should  be  observed  in  treating  wounds  of  the  face  ? 

Secure  most  accurate  coaptation.  Avoid  sutures  in  superficial 
wounds,  closing  by  means  of  iodoform,  ether,  and  collodion.  In 
wounds  involving  the  cartilages  of  the  nose  or  ear,  pass  sutures 
only  through  the  skin.  In  operations,  so  place  the  incision  that 
it  may  correspond  with  the  natural  lines  of  the  face.  If  stitches 
are  inserted,  remove  them  in  twenty-four  hours. 

How  do  you  treat  salivary  fistula  ? 

This  is  usually  caused  by  a  wound  of  Steno's  duct.  Treat  by 
passing  a  thread  around  the  duct  from  the  inside  of  the  cheek 
posterior  to  the  external  opening.  When  this  thread  has  ulce- 
rated an  opening  into  the  mouth,  the  external  wound  will  usually 
heal.     If  not,  freshen  its  edges  and  suture. 


WOUNDS. 


91 


Wounds  of  the  Neck, 

(For  the  anatomy  of  the  Cervical  Triangles,  see  Ligations.) 

Describe  wounds  of  the  neck. 

These  wounds  are  commonly  incised  suicidal  wounds.  They 
extend  obhquely  from  left  to  right,  and  from  above  downward, 
and  are  deepest  at  their  starting-point.  They  are  most  fre- 
quently found  in  the  laryngeal  region,  particularly  over  or 
through  the  thyrohyoid  membrane.  The  carotid  arteries  are 
rarely  injured,  the  wound  being  usually  placed  too  high,  and  the 
larynx  and  trachea  bearing  the  brunt  of  the  incision.  These 
wounds  may  be  loenetr citing  or  non-penetrating. 

Wounds  above  the  hyoid  bone  may  divide  the  tongue,  the  lingual 
and  facial  arteries,  and  the  hypoglossal  nerve.  There  is  great 
gaping  ;  frequently  escape  of  food  and  saliva. 

Wounds  through  the  thyro-hyoid  membrane  open  the  pharynx, 
and  may  involve  the  epiglottis,  the  superior  thyroid  and  lingual 
arteries,  and  the  superior  laryngeal  nerves. 

Wounds  through  the  cartilages  may  involve  the  vocal  cords  and 
the  recurrent  laryngeal  nerve.  There  is  usually  but  moderate 
bleeding. 

JVounds  below  the  cartilages  may  involve  the  superior  or  inferior 
thyroid  arteries,  the  thyroid  and  anterior  jugular  veins,  the 
trachea,  and  even  the  oesophagus. 

What  are  the  immediate  dangers  of  penetrating  neck  wounds  ? 

1.  Hemorrhage,  arterial  or  venous. 

2.  Suffocation  from  the  plugging  of  the  air-passages,  with  either 
blood-clot,  the  tongue,  the  epiglottis,  or  the  divided  cartilages. 

.3.  Entrance  of  air  into  the  veins. 

What  are  the  secondary  dangers  of  penetrating  neck  wounds? 
CEdema  of  larynx,  emphysema,  bronchitis  or  broncho-pneu- 
monia, cellulitis,  cicatricial  contraction  and  stricture. 

How  do  you  treat  penetrating  neck  wounds  ? 

Check  bleeding,  ligate  both  ends  of  every  bleeding  vessel.  The 
common   carotid   should   only  be    tied   for  bleeding   from    its 


92  ESSENTIALS    OF    SURGERY. 

branches,  when  it  is  found  impossible  to  tie  the  branches.  If  the 
external  carotid  is  wounded  at  its  origin,  tie  the  connnon  carotid, 
the  external  carotid,  and,  to  avoid  bleeding  from  collateral  circu- 
lation, the  internal  carotid. 

If  the  larynx  is  obstructed  by  blood-clot,  clear  by  the  fingers, 
by  suction,  or  by  forcing  the  air  suddenly  from  the  chest.  Re- 
move a  partially  severed  portion  of  the  epiglotlis.  Hold  the 
divided  tongue  forward  by  a  ligature  passed  through  its  tip. 

Wounds  of  tbe  oesophagus  should  be  closed  by  catgut  sutures. 
If  the  trachea  is  completely  divided  across,  the  two  ends  may  be 
held  in  apposition  by  fine  catgut  sutures  passed  through  the  invest- 
ing cellular  tissue.  The  external  wound  should  not  be  sutured  ; 
its  surfaces  are  apposed  by  raising  the  head,  and  supporting  it  in 
one  position  bj^  pillows  and  sand-bags,  or  by  a  gutta-percha  splint. 

Provision  is  made  for  free  drainage,  and  Hght  antiseptic  dress- 
ing is  applied.  If  dyspncea  appears,  perform  tracheotomy  lower 
down,  or  insert  a  tracheal  canula  through  the  wound.  Feed  by 
the  rectum  for  four  days,  then  by  an  oesophageal  tube,  passed 
just  beyond  the  wound.  jS'on-penetrating  wounds  are  treated 
as  wounds  in  any  other  part  of  the  bodJ^ 


Wounds  of  the  Chest. 

Describe  non-penetrating  wounds  of  the  chest. 

A  non-penetrating  chest  wound  is  one  which  does  not  involve 
the  costal  pleura.  In  chest  wounds  the  finger  must  be  used  as  a 
probe,  and  great  care  taken  lest  a  non-penetrating  be  converted 
into  a  penetrating  wound.  Hemorrhage  must  be  absolutely 
checked  before  closing,  and  the  wound  approximated  by  deep 
sutures  passed  to  its  very  bottom.  Firm  pressure  is  applied  over 
the  antiseptic  dressing,  by  a  bandage  carried  around  the  chest. 

These  wounds  may  involve  the  brachial  plexus,  the  intercostal, 
internal  mammary,  acromio-thoracic,  long  thoracic,  or  axillary 
arteries.   Check  bleeding  by  ligature  or  hsemostatic  forceps. 

Describe  penetrating  wounds  of  the  chest. 

The  pleura  and  lung,  the  pericardium  and  heart,  or  the  great 
vessels  may  be  wounded. 


WOUNDS.  93 

Injuries  of  the  pleura  and  lung  are  characterized  hy  shocks 
dyspnoea,  pain,  cough,  abdominal  breathing,  eo:pectoraiion  of 
frothy  hlood-stained  mucus,  escape  through  the  wound  of  a  hloody 
froth  accompanied  hy  a  hissing  sound  {tromatopmoea),  emphysema, 
pneumothorax,  external  bleeding,  htemothorax.  In  case  the 
pleura  alone  i^  injured  there  will  be  no  h8emopt3'sis  and  no 
bloody  froth  from  the  wound. 

Prognosis,  grave  in  wounds  involving  the  root  of  the  lung, 
and  in  gunshot  wounds  which  penetrate  but  do  not  perforate. 

Injuries  to  the  pjericardium  and  heart  are  characterized  by  great 
shock,  hemorrhage,  and  the  subsequent  development,  if  the  pa- 
tient lives  long  enough,  of  pericarditis.  Death  in  wounds  of  the 
pericardium  occurs  from  shock,  the  pressure  effect  of  heemoperi- 
cardium,  or  from  pericarditis. 

What  are  the  complications  of  penetrating  wounds  of  the  chest? 

External  bleeding,  htemothorax,  emphysema,  pneumothorax, 
pleurisy,  pneumonia,  prolapse  of  lung. 

How  do  you  treat  the  external  bleeding  of  penetrating  chest 
wounds  ? 

If  from  an  intercostal  artery  ligate,  or  apply  haemostatic  forceps  ; 
this  being  impossible,  dissect  off  the  periosteum  from  the  lower 
part  of  the  rib  (carrying  the  artery  with  it  of  course)  and  tie ;  or 
resect  a  portion  of  the  rib.  A  ligature  may  be  carried  around 
the  entire  rib. 

If  from  the  interned  mammary,  ligate  in  the  wound,  resecting 
the  chondral  cartilages  if  necessary. 

If  from  the  lung,  close  the  external  wound,  place  the  patient 
on  the  injured  side,  and  apply  an  ice-bag.  Internally  give 
opdum,  ergot,  gallic  acid.  If  the  bleeding  continues,  producing 
constitutional  signs  of  hemorrhage,  and  local  signs  of  extensive 
hsemothorax,  open  again  and  allow  the  blood  to  escape. 

Describe  hsemothorax. 

Definition.     Bleeding  into  the  pleural  sac. 

Usual  cause.  Wound  of  the  lung,  or  of  an  intercostal  artery 
by  a  broken  rib. 

Syraptoms.    Those  of  internal  hemorrhage,  together  with  bulg- 


94  ESSENTIALS    OF    SURGERY. 

ing  of  the  intercostal  spaces,  increasing  dyspnoea,  flatness  on 
percussion,  and  absence  of  breathing  sounds.  The  symptoms 
appear  almost  immediately  after  the  injury.  Inflammatory 
effusions  do  not  take  place  till  some  days  later. 

Treatment.  As  for  external  bleeding  from  lungs.  Aspirate 
or  open  if  there  is  threatening  dyspnoea.  If  suppuration  takes 
place,  open  freely  and  drain. 

Describe  pneumothorax. 

Cause.     Injury  to  lung  and  pleura,  usually  by  a  broken  rib. 

Symptoms.  The  lung  collapses.  Increasing  dyspnoea,  great 
percussion  resonance,  amphoric  breathing,  metallic  tinkling, 
bulging  of  intercostal  spaces. 

Treatment.     Should  dyspnoea  become  urgent,  aspirate. 

Describe  emphysema. 

Cause.  Wound  of  the  lung  and  pleura.  It  may  arise  after 
wound  of  the  lung  alone,  in  this  case  extending  by  way  of  the 
root  to  the  posterior  mediastinum,  and  from  there  into  the  con- 
nective tissue  of  the  neck  and  arms. 

Symptoms.  A  diffused,  colorless,  elastic,  puffy  swelling, 
crackling  on  pressure. 

Treatment.  A  compress  and  bandage  over  the  wound.  Should 
distension  become  great,  puncture. 

How  do  you  treat  prolapse  of  the  lung  ? 

Eeturn  if  not  adherent.  If  adhesions  have  taken  place,  ligate 
or  excise,  taking  precautions  against  opening  the  pleural  cavity. 

Describe  hernia  of  the  lung. 

Causes.  The  yielding  of  a  cicatrix.  The  result  of  subcutaneous 
wound.     Great  muscular  effort. 

Symptoms.  A  soft  circumscribed  tumor,  resonant  on  percus- 
sion, giving  a  loud  respiratory  murmur,  and  crepitating  on 
manipulation. 

Treatment.     Protective. 

What  is  concussion  of  the  lung  ? 

A  condition  following  traumatism.  Characterized  by  dyspnoea, 
feeble  respiratory  murmur,  and  slight  dullness  on  percussion. 
The  symptoms  pass  off"  after  a  few  hours. 


woui^DS.  95 

What  operations  may  be  done  for  the  evacuation  of  blood  or  in- 
flammatory effusion  within  the  chest  walls  ? 

1.  Tapping  the  pleura.  For  serous  effusion.  Thrust  an  as- 
pirating needle  through  the  sixth  intercostal  space,  in  the  mid 
axillary  line.  This  operation  must  be  done  under  antiseptic 
precautions.  The  skin  is  drawn  down  before  the  puncture  is 
made,  forming  a  valvular  wound.  Dress  with  iodoform  and 
collodion. 

2.  Incision  and  drainage  of  pleura.  For  empyema  and  the  re- 
moval of  decomposing  clots.  Operate  in  the  sixth  intercostal 
space,  in  the  axillary  line,  or  as  low  as  the  eleventh  space,  in  a 
line  with  the  angle  of  the  scapula.  Make  a  careful  dissection. 
Excise  a  portion  of  the  rib  if  necessary,  and  insert  a  drainage 
tube. 

3.  Tapping  the  pericardiimi.  Fourth  intercostal  space  two 
inches  to  the  left  of  the  sternum. 

4.  Incision  and  drainage  of  pjericardium.  Beginning  one  inch 
from  sternum,  make  an  incision  two  inches  in  length  along  the 
upper  border  of  the  fifth  or  sixth  ribs.  Dissect  down  carefully, 
insert  drainage  tube  after  opening. 

5.  Pneumotomy.  Lung  incision  for  abscess,  gangrene,  or 
cysts.  Open  down  to  the  pleura,  thrust  a  trocar  and  canula  into 
the  affected  area.     Enlarge  this  puncture  by  dressing  forceps. 

Wounds  of  the  Abdomen. 

Describe  contusion  of  the  abdomen. 

Contusion  may  take  ptlace  with^  or  without,  rupAure  of  the  contained 
viscera. 

Contusion  without  rupture  of  the  contained  viscera  is  character- 
ized by  pain,  discoloration,  swelling,  and  shock.  The  rectus 
muscle  may  be  ruptured,  or  there  may  be  a  hsematoma  formed, 
followed  by  abscess. 

Treatment.  Put  the  patient  to  bed,  apply  heat  to  the  body, 
hot  fomentations  to  the  abdomen.  Give  water  and  cracked  ice 
for  twenty-four  hours.  Treat  rupture  of  the  rectus  by  position. 
Apply  cold  in  case  of  hajmatoraa.     Evacuate  abscesses  early. 


96  ESSENTIALS    OF    SURGERY. 

What  symptoms  denote  contusion  with  laceration  of  the  viscera? 

Great  shock,  pain,  jjersistence  of  collapse  with  signs  and  symp- 
toms of  internal  Meeding,  in  case  the  solid  viscera  or  a  highly 
vascular  portion  of  the  peritoneum  is  ruptured,  symptoms  of 
rapidly  developing  'peritonitis  in  case  the  hollow  viscera  are 
ruptured. 

The  following  signs,  if  present,  are  indicative  of  rupture  of 
the  individual  viscera. 

Liver.  Pain  in  right  hj^pochondrium,  increased  hepatic  dull- 
ness, signs  of  internal  bleeding;  later,  bilious  vomiting,  clay- 
colored  stools,  sugar  in  the  urine. 

Spleen.     Pain  in  left  side,  increased  splenic  dullness. 

Stomach.  Intense  pain  in  stomach,  hseraatemesis,  rapid  de- 
velopment of  general  meteorism,  tympany  over  the  liver. 

Intestines.  Intense  radiating  pains.  Vomiting  of  stomach 
contents,  then  bile,  finally  blood.  Bloody  stools.  Tympanites 
with  dullness  in  the  flanks.  Percussion  resonance  over  liver. 
Peritonitis. 

Kidneys.  Frequent  passage  of  bloody  urine,  with  extravasa- 
tion in  the  loin. 

In  all  cases,  the  portion  of  the  body  which  received  the  brunt 
of  violence  must  be  considered,  in  determining  what  internal 
organs  are  probably  injured. 

How  do  you  treat  abdominal  contusion  with  rupture  of  con- 
tained viscera  ? 

Absolute  rest.     Opium. 

If  symptoms  characteristic  of  internal  hemorrhage,  or  rupture 
of  a  hollow  viscus,  appear,  do  an  exploratory  laparotomy.  Bleeding 
from  the  liver  or  spleen  can  be  checked  by  iodoform  tamponade, 
or  by  the  actual  cautery.  Torn  vessels  in  the  peritoneum  can 
be  ligated.  Eents  in  the  stomach  or  intestines  can  be  united  by 
sutures  or  brought  to  the  surface.  By  irrigation,  the  peritoneal 
cavity  can  be  freed  of  blood  and  extra vasated  matter.  Buptured 
kidney  with  lumbar  extravasation  should  be  treated  by  free 
lumbar  incision  and  drainage. 

What  are  the  causes  of  traumatic  peritonitis  ? 
The  bursting  of  an  abscess,  or  the  extravasation  of  urine, 


WOUNDS.  97 

blood,  bile,  or  the  contents  of  the  alimentary  canal  into  the 
peritoneal  cavity. 

Termination  usually  fatal,  from  collapse  or  blood  poison. 

What  are  the  symptoms  of  traumatic  peritonitis  ? 

Severe  pain,  at  first  local,  then  general. 

Extreme  tenderness.  Dorsal  decubitus  with  legs  and  thighs 
drawn  up.  Breathing  thoracic.  Abdomen  distended  and  tym- 
panitic; later,  dull  in  the  flanks  from  effusion.  Obstinate 
vomiting.  Complete  constipation  Small^  quick,  wiry  pulse.  Dry 
brown  tongue.     Temperature  103°  to  104P. 

In  the  septicsemic  form  there  may  be  little  pain  or  tenderness, 
and  a  normal  or  even  subnormal  temperature  throughout 

How  do  you  treat  traumatic  peritonitis? 

Prevent  by  absolute  rest,  cracked  ice  diet,  hot  fomentations, 
laparotomy. 

Treat,  on  the  development  of  the  first  symptom,  by  a  full  saline 
purge  and  turpentine  enema.  Open  and  wash  out  the  peritoneal 
cavitJ^  Insert  a  glass  drainage  tube.  Stimulants  and  nourish- 
ment in  teaspoonful  doses. 

Or  treat  expectantly,  apply  leeches  to  the  abdomen,  followed 
by  hot  fomentations  or  turpentine  stupes.  Give  opium  till  the 
respirations  are  reduced  to  twelve  in  the  minute. 

How  do  you  treat  non-penetrating  wounds  of  the  abdomen  ? 

Chech  all  bleeding.  Extensive  extravasation  may  take  place 
between  the  muscular  planes  if  this  precaution  is  not  observed. 
Pass  sutures  to  the  bottom  of  the  wound,  approximating  accurately. 
Prevent  tension  by  position.  Apply  an  antiseptic  dressing,  and  a 
binder  about  the  body. 

If  signs  of  inflammation  appear,  open  freely  (abdominal  ab- 
scesses do  not  point).     Guard  against  subsequent  hernia. 

Describe  penetrating  wounds  of  the  abdomen. 

These  wounds  involve  the  peritoneal  cavity.   There  may  be — 

1.  Simple  penetration  without  visceral  injury  or  protrusion. 

2.  Penetration  with  visceral  injury,  but  no  protrusion. 

3.  Penetration  with  visceral  protrusion,  but  no  injury. 

4.  Penetration  with  both  protrusion  and  injury. 

•  7 


98  ESSENTIALS    OF    SURGERY. 

How  do  yon  treat  simple  penetrating  abdominal  wonnds  ? 

Thoroughly  cleanse.  Close  the  wound  by  sutures  passed  from 
within  outward,  including  the  peritoneum  and  the  entire  thick- 
ness of  the  abdominal  wall.  Apply  an  antiseptic  dressing  and  a 
binder  about  the  body,  and  place  the  patient  in  that  position 
which  will  most  eflfectually  relax  the  wounded  muscles.  Give 
internally  cracked  ice  for  two  days,  then  milk  in  small  quan- 
tities. Opium,  if  indicated  by  pain  or  diarrhoea.  If  there  has 
been  hemorrhage  into  the  peritoneal  cavity,  remove  all  blood 
by  irrigation  and  insert  a  glass  drainage-tube. 

How  do  yon  treat  penetrating  wounds  with  visceral  injury? 

Enlarge,  if  necessary,  and  treat  the  visceral  injury.  Check 
bleeding  from  the  liver  and  spleen  by  cautery,  or  iodoform  tam- 
pons. Drain  small  wounds  of  the  kidney.  If  the  organ  be  ex- 
tensively lacerated,  do  a  nephrectomy.  Wounds  of  the  ureter 
require  either  a  nephrectomy,  or  the  formation  of  a  urinary 
fistula  by  bringing  the  ureter  to  the  surface.  Wounds  of  the 
stomach  or  intestines  should  be  sutured ;  if  large,  the  sutured 
portion  may  be  secured  in  the  wound,  the  latter  not  being  closed 
immediately  (iodoform  tamponade).  Extravasation  will  then 
take  place  externally  if  the  sutures  yield.  Slight  punctures  are 
closed  by  prolapse  of  the  mucous  membrane,  and  do  not  require 
suturing. 

How  do  you  determine  as  to  the  existence  of  a  visceral  injury  in 
penetrating  abdominal  wounds? 

If  the  wound  is  large,  inspection  and  palpation  may  be  suffi- 
cient. 

In  small  wounds  intense  pain  and  severe  collapse^  .with  or  with- 
out escape  of  fceces,  gas,  hile,  serum,  or  food,  indicate  the  nature 
of  the  injury. 

Wounds  of  the  stomach  and  intestines  usually  give  a  clear 
tympanitic  percussion  note  over  the  liver. 

In  case  of  doubt  inject  hydrogen  gas  into  the  rectum  ;  if  the 
stomach  or  intestines  are  wounded,  the  gas  will  escape  through 
the  wound.    Where  there  is  no  evidence  of  visceral  wound  treat 


WOUNDS, 


99 


as  penetrating  wound,  performing  an  exploratory  laparotomy  on 
the  first  sign  of  internal  hemorrhage  or  traumatic  peritonitis. 

How  do  you  suture  the  intestine  ? 

By  the  Lembert  interrupted  suture.    The  threads  include  only 
the  serous  and  muscular  coats  of  the  bowel,  are  made  of  sterilized 

Fiff.  6. 


Lembert  suture. 

China  silk,  and  are  placed  a  twelfth  of  an  inch  apart.  The 
suture  is  designed  to  approximate  serous  surfaces.  It  passes  in 
and  out  on  one  side  of  the  wound,  across,  and  in  and  out  on  the 
other  side,  and  is  then  tied.  If  the  intestine  is  entirely  torn 
across,  or  extensively  injured,  a  portion  may  be  resected,  a  V- 
shaped  piece  of  mesentery  removed,  and  the  gut  ends  united 
by  first  bringing  the  peritoneal  coat  together  by  a  circle  of  in- 
terrupted sutures,  then  invaginating  the  incision  and  approxi- 
mating serous  surfaces  by  Lembert's  suture.  This  constitutes 
Czernifs  suture.  Or,  the  gtit  ends  may  be  sutured  through  half 
their  circumference,  and  the  remaining  opening  secured  in  the 
wound,  making  an  artificial  anus. 

How  do  you  treat  penetrating  abdominal  wounds  with  protru- 
sion of  viscera  ? 

Carefully  cleanse  and  return.  If  intestine  is  gangrenous,  in- 
cise and  leave  in  the  wound  ;  if  congested  and  adherent,  free 
from  adhesions  and  return.  The  abdominal  wound  may  be 
enlarged  if  necessary.  Congested  omentum  should  be  ligated, 
removed,  and  the  stump  returned  to  the  abdominal  cavity.     If 


100  ESSENTIALS    OF    SURGERY. 

the  intestines  protrude  and  are  wounded,  apply  a  Lembert  suture 
and  return,  or  make  an  artificial  anus. 

In  all  extensive  injuries  do  not  close  the  abdominal  wound  ab- 
solutely. Insert  sutures,  knot  them  loosely,  and  pack  the  wound 
with  iodoform  gauze.  When  danger  from  intra-peritoneal  com- 
plications has  passed  away,  approximate  the  granulating  surfaces 
by  removing  the  packhig  and  drawing  the  sutures  tight.  The 
wound  heals  by  secondary  adhesion  (third  intention). 

Describe  laparotomy. 

Preparation  most  thoroughly  antiseptic.  Incision  in  median 
line.  Check  all  hemorrhage  by  haemostatic  forceps  before  open- 
ing peritoneum.  The  latter  is  nicked,  held  up  by  two  fingers, 
and  divided  by  scissors.  Insert  a  large  flat  sponge  to  catch  all 
oozing  from  wound.  Irrigate  the  abdominal  cavity,  if  necessary, 
with  warm  distilled  water.  If  there  is  much  shock,  use  hot-water 
(not  over  106°).  After  the  completion  of  the  operation  dry  with 
sponges,  inserting  glass  drainage-tube  if  there  has  been  much 
manipulation  or  hemorrhage  ;  close.  First  bring  the  peritoneum 
together  with  a  line  of  interrupted  catgut  sutures  ;  then  insert 
some  plate  sutures  of  relaxation,  using  silk-worm  gut.  Suture 
together  the  fibrous  investments  of  the  two  rectus  muscles  ;  finally 
unite  the  skin  and  subcutaneous  tissues  with  interrupted  sutures 
of  approximation  and  continuous  sutures  of  coaptation. 

Dust  with  iodoform,  apply  a  strip  of  protective,  several  layers 
of  iodoform  gauze,  a  thick  investment  of  bichloride  cotton,  Mack- 
intosh, and  a  moderately  tight  binder. 

Grive  cracked  ice  for  two  days.  Stimulants  as  required.  See 
that  the  bladder  is  -regularly  emptied^  drawing  the  water  if 
necessary. 

Describe  tapping  of  the  abdomen. 

This  operation  is  done  for  ascites. 

See  that  the  bladder  is  empty,  pass  a  many-tailed  bandage 
about  the  body  to  make  pressure,  let  the  patient  sit  up,  leaning 
somewhat  forward,  make  a  skin  incision  in  the  linea  alba,  mid- 
way between  the  umbilicus  and  pubis,  and  thrust  the  trocar  and 
canula  into  the  abdomen.     To  avoid  syncope  draw  ofi"  slowly, 


WOUNDS.  101 

gradually  tighten  the  bandage  as  the  liquid  flows  away,  and  let 
the  patient  lie  down. 

Describe  rupture  of  the  bladder. 

Cause.  A  blow  or  kick  when  the  bladder  is  full.  Fracture 
of  the  pelvis.  Yery  rarely  from  simple  over-distension.  In  re- 
tention from  stricture  the  urethra  more  commonly  gives  way. 

The  rupture  is  usually  vertical.  Occurs  more  commonly  in 
the  posterior  part,  when  the  urine  escapes  into  the  peritoneal 
cavity,  causing  peritonitis.  May  occur  in  the  anterior  part,  with 
extravasation  into  the  loose  cellular  tissue  of  the  pelvis,  causing 
cellulitis  with  secondary  peritonitis  or  septic  poisoning. 

What  are  the  symptoms  of  ruptured  bladder  ? 

Collapse  following  an  injury  to  the  abdomen  or  pelvis,  with 
absence  of  urine  and  presence  of  blood  in  the  bladder,  as  demon- 
strated by  passing  a  catheter.  If  the  patient  has  passed  his 
urine  immediately  before  the  injury,  inject  two  ounces  of  warm 
boracic  acid  solution  (4  per  cent.)  into  the  bladder ;  if  there  is 
an  extensive  rent  in  its  walls,  the  solution  will  escape  and  can- 
not again  be  drawn  off  by  a  catheter.  A  catheter  may  some- 
times be  felt  to  pass  through  the  rent. 

How  do  you  treat  rupture  of  the  bladder  ? 

Bo  a  supra-pubic  cystotomy.  If  the  rent  is  extra-peritoneal, 
insert  a  drainage  tube.  If  the  rent  is  intra-peritoneal,  open  the 
peritoneal  cavity  (through  the  same  parietal  incision),  irrigate 
thoroughly  to  wash  away  all  urine.  Close  the  rent  by  the 
Czerny  suture,  taking  particular  care  to  see  that  no  thread 
pierces  the  mucous  membrane.  Insert  a  drainage  tube,  tampon 
the  external  wound  with  iodoform  gauze,  and  let  the  patient 
insure  free  drainage  by  the  lateral  decubitus. 

These  ruptures  may  be  treated  by  the  introduction  and  reten- 
tion of  a  soft  catheter  passed  through  the  urethra. 


102  ESSENTIALS    OF    SURGERY 


Burns  and  Scalds. 

How  are  burns  classified  ? 

Burns  are  of  six  degrees. 

1st  Degree.  Simple  erythema  followed  by  slight  desquamation. 
There  is  no  tissue  destruction. 

2d  Degree.  Vesication.  The  superfical  layers  of  the  epiderm 
are  destroyed. 

3c?  Degree.  Destruction  of  the  epiderm  and  the  greater  part  of 
the  true  skin.  A  portion  of  the  papillary  layer,  and  the  epithe- 
lium about  the  hair  follicles  and  sebaceous  glands  escapes. 
This  is  of  great  importance  in  the  subsequent  healing,  as  skin- 
ning starts  from  these  points  as  islands,  and  the  elements  of  true 
skin  are  preserved  to  an  extent.  There  is  scarring,  but  not 
marked  contractions.  This  is  the  most  painful  form  of  burn, 
from  involvement  of  the  nerve-endings. 

^th  Degree.  Destruction  of  the  skin  and  subcutaneous  tissue. 
Scarring  and  contractions. 

5th  Degree.  The  deep  fascia  Is  penetrated  and  the  muscles  are 
involved. 

6th  Degree.     Destruction  of  the  entire  part. 

Describe  the  constitutional  effects  of  severe  burns. 

Dependent  on  the  extent  of  surface  involved^  and  the  depth. 
Three  stages. 

1.  Shock  and  internal  congestion.  Most  marked  in  extensive 
burns  of  the  trunk  and  head.  The  patient  shivers  and  complains 
of  cold. 

2.  Beaction  and  inflammation.  Coming  on  in  from  one  to  two 
days.  The  patient  complains  of  thirst  and  inflammatory  fever. 
Internal  congestion  may  run  on  to  inflammation,  causing  menin- 
gitis, pleurisy,  or  peritonitis,  according  to  the  seat  of  the  burn 
(head,  chest,  abdomen).  Duodenal  ulcer  and  nephritis  are  fre- 
quent complications, 

3.  Suppuration  and  exhaustion^  setting  in  on  the  separation  of 
sloughs.     The  patient  often  complains  of  cough  and  diarrhoea, 


WOUNDS.  103 

and  may  now  perish  from  amyloid  degeneration,  exhaustion,  or 
blood  poison. 
Great  deformity  ensues  on  cicatrization  of  deep  burns. 

What  is  your  prognosis  in  severe  burns  ? 

Bad  in  burns  involving  one-third  the  surface,  and  in  extensive 
burns  upon  the  trunk.  Fatal  cases  mostly  perish  within  forty- 
eight  hours  from  shock. 

How  do  you  treat  burns  ? 

Constitutionally.  Treat  the  shock  by  external  heat,  hot  bath, 
hypodermics  of  brandy,  ammonia,  atropia,  and  morphia.  See 
that  there  is  no  retention  of  urine.  When  reaction  and  inflam- 
mation appear  give  a  saline  cathartic,  neutral  mixture.  If 
the  kidneys  are  congested  apply  dry  cups,  hot  fomentations. 
Give  liquid  nourishment  in  small  doses  frequently  repeated. 
Keep  up  the  use  of  stimulants.  Allay  thirst  by  cracked  ice. 
During  the  third  stage  give  tonics  and  stimulants,  push  the 
nourishment,  and  treat  diarrhoea  by  opium  and  astringents. 

Locally.  All  burns  beyond  those  of  the  first  degree  should  be 
washed  and  dressed  under  all  antiseptic  precautions. 

Burns  of  the  second  degree.  Wash  with  1 :  2000  sublimate  solu- 
tion, shave  the  surrounding  skin,  remove  all  loosened  epithelium, 
wash  again  with  1 :  2000,  using  a  soft  brush  or  sponge  for  the  in- 
jured surface,  complete  the  cleansing  with  1 :  5000  sublimate 
solution,  cover  with  strips  of  protective  wet  in  1  :  5000,  sprinkle 
iodoform  over  the  protective,  apply  a  thick  layer  of  iodoform 
gauze  overlapping  the  protective,  a  still  larger  and  thicker  layer 
of  bichloride  gauze,  finally  bichloride  cotton  and  a  bichloride 
bandage.    Cure  in  ten  days  on  removal  of  the  dressing. 

Burns  of  the  third  and  fourth  degrees,  if  limited  in  extent,  are 
treated  as  burns  of  the  second  degree.  Eemove  dressings  when 
•they  become  rank  (ten  days),  thoroughly  bathe  in  1  :  5000,  trim 
away  sloughs,  re-dress.  When  sloughs  are  all  removed,  and  the 
burn  converted  to  a  granulating  surface,  skin  graft. 

When  the  burn  is  very  extensive  cleanse,  wash,  and  remove 
loose  cuticle  as  before,  liberally  sprinkle  each  region  so  treated 
with  subnitrate  of  bismuth,  cover  with  a  single  layer  of  lint  or  soft 


104  ESSENTIALS    OF    SURGERY. 

linen,  held  in  place  by  one  or  two  adhesive  strips.  Twice  a  day 
gently  raise  the  edges  of  the  lint,  and  sprinkle  more  bismuth 
wherever  the  coating  has  become  loosened  by  discharge. 

Or,  puncture  vesicles,  but  do  not  remove  the  cuticle,  apply  lint 
saturated  in  carron  oil  (lime-water  and  linseed  oil  in  equal  parts), 
and  cover  in  with  waxed  paper  and  a  light  bandage.  Change  the 
dressing  daily,  uncovering  a  small  amount  of  surface  at  a  time,  and 
redressing  one  part  before  another  is  exposed. 

In  extensive  deep  burns  the  continued  warm  bath  may  be  em- 
ployed till  the  sloughs  separate. 

Relieve  the  pain  of  burns  of  the  first  degree  by  white-lead 
paint. 

Opium  is  indicated  in  all  stages  of  severe  burns. 


FRACTURES.  105 


FRACTURES. 

What  is  a  fracture  ? 

The  sudden  solution  in  the  continuity  of  a  bone. 

What  are  the  causes  of  fracture  ? 

1.  Predisposing. 

a.  Local.     Function,  form,  position,  disease  of  the  bone. 

5.  Constitutional.     Includes  conditions  under  which  the 

bone  becomes  fragile,  or  subject  to  disease  or  injury 
— such  as  age,  sex,  rickets,  locomotor  ataxia,  and  ne- 
crosis. 

2.  Exciting. 

a.  External  violence. 

6.  Muscular  action. 

What  are  the  varieties  of  fracture  ? 

Incomplete^  partial,  or  greenstick.  The  bone  is  bent,  but  not 
entirely  broken  through. 

Stellate,    grooved,   and  ^^    ,    _      ^^'    ' 

fissured  fractures  are 
also  classed  as  incom- 
plete. 

Com%)lete.    The  break 
involves  the  entire  thick- 

^r.cr,  ^f  4-1.^  v>^^^  Greenstick  fracture  of  clavicle. 

ness  of  the  bone. 

Simple.  Not  accompanied  by  an  open  wound  leading  down 
to  the  break.     A  single  uncomplicated  fracture. 

Compound.  Accompanied  by  a  wound  leading  down  to  the 
break. 

Sinfjle.  Having  but  one  line  of  fracture,  making  in  the  long 
bones  two  fragments. 

Multiple.  Two  or  more  fractures,  the  lines  of  breakage  not 
communicating  if  these  fractures  are  of  the  same  bone. 

Comminuted.  The  bone  is  broken  into  more  than  two  pieces, 
the  lines  of  fracture  communicating. 


106  ESSENTIALS    OF    SURGERY. 

Impacted.  One  fragment  is  driven  into  the  other,  and  fixed 
in  that  position. 

Complicated.  Accompanied  by  an  injury  to  some  other  im- 
portant parts  in  the  same  region,  as  joints,  bloodvessels,  nerves, 
or  muscles. 

Further,  fractures  about  joints  are  classed  as  : — 

Intracapsular — within  the  capsular  ligament. 

Extracapsular— without  the  capsular  ligament. 

In  young  persons  epiphyseal  separation  occurs,  especially  in 
the  humerus,  and  constitutes  epiphyseal  fracture. 

In  what  direction  does  the  line  of  fracture  extend? 
It  is  generally  oblique^  but  may  be  transverse^  from  direct  vio- 

Fig.  8. 


Oblique  and  transverse  fracture  of  the  tibia. 

lence,  longitudinal^  when  force  is  applied  in  the  direction  of  the 
long  axis  of  the  bone,  spiral  or  stellate. 

What  are  the  sjnnptoms  of  fracture  ? 

1.  Deformity  or  displacement  due  to  1,  the  fracturing  force  ; 
2,  the  muscular  contractility  ;  3,  the  weight  of  the  part. 

2.  Abnormal  mobility . 

3.  Crepitus^  or  harsh  grating,  both  felt  and  heard  on  manipu- 
lation. 

4.  Loss  of  function. 

5.  Paiyi  and  tenderness^  sharp  and  severe. 

6.  Swelling  and  ecchymosis^  the  latter  appearing  in  certain 
lines. 

What  are  the  different  kinds  of  displacement  ? 

Angular  or  bending,  rotary  or  twisting,  transverse,  longitudinal 
or  overlapping. 


FRACTURES.  107 

When  have  you  difficulty  in  recognizing  displacement? 

When  but  one  of  two  parallel  bones  is  broken,  or  when  the 
short,  flat  bones  are  involved. 

Under  what  circumstances  is  crepitus  absent  ? 

In  greenstick  and  impacted  fractures ;  when  the  fragments 
overlap  considerably  or  are  widely  separated  ;  when  soft  tissue 
is  interposed  between  the  ends  of  bone. 

In  epiphyseal  fracture  we  have  moist  crepitus  only. 

What  fractures  do  not  present  abnormal  mobility  ? 

Greenstick  and  impacted  fractures. 

How  do  you  diagnose  a  fracture? 

Deformity^  unnatural  mohility,  and  crepitus^  if  elicited,  are 
absolutely  diagnostic.  If  great  swelling  prevents  a  positive 
diagnosis,  treat  as  a  fracture  till  swelling  subsides. 

What  is  the  general  treatment  of  all  fractures  ? 

1.  Keduce  the  fracture. 

2.  Retain  it  in  position. 

3.  Treat  inflammation  and  other  complications,  either  consti- 
tutional or  local. 

How  do  you  reduce  a  fracture  ? 

1.  By  extension  or  traction,  made  by  the  surgeon  steadily 
pulling  upon  the  lower  fragment. 

2.  Counter-extension  or  fixation  of  the  upper  fragment. 

3.  Coaxjtaiion  or  adjusting  the  broken  ends  of  the  bone  to 
their  proper  position. 

How  do  you  overcome  muscular  spasm? 

If  muscular  spasm  interferes  with  reduction,  it  must  be  over- 
come by  position,  etherization,  or  tenotomy. 

How  do  you  retain  the  bones  in  proper  position  ? 

By  means  of  splints  and  bandages.  Splints  may  be  made  of 
wood,  tin,  gutta-percha,  binders'  board,  leather,  etc. 

Bandages  may  be  made  of  muslin,  linen,  or  gauze,  or  may 
have  incorporated  with  them  various  materials  which,  harden- 


108  ESSENTIALS    OF    SURGERY. 

ing,  make  a  solid  and  firm  dressing,  as  plaster,  silicate  of  potas- 
sium, gmn,  etc. 

Under  what  circumstances  are  the  fixed  dressings,  as  plaster, 
applied? 

Primarily,  in  fractures  attended  with  little  swelling,  displace- 
ment, or  damage  to  the  soft  parts.  Secondarily,  in  fractures  of 
the  lower  extremity,  after  the  subsidence  of  swelling  and  inflam- 
matory symptoms. 

What  rules  guide  you  in  the  application  of  splints  ? 

1.  Splints  should  be  well  padded. 

2.  They  should  fix  the  joints  above  and  below  the  break. 

3.  The  extremities  of  the  limbs  should  be  left  exposed  to  view 
(fingers  and  toes). 

Circular  compression  must  be  avoided,  primary  rollers  being 
absolutely  discarded  in  fractures  of  the  leg  or  forearm.  Applied 
with  great  caution  in  fractures  of  the  thigh  or  upper  arm. 

How  often  do  you  re-dress  a  fracture  ? 

The  fracture  dressing  must  be  inspected  daily  for  one  week. 
If  too  loose  or  too  tight,  or  if  there  is  evidence  of  displacement, 
the  dressing  must  be  renewed.  Otherwise,  twice  weekly  will 
be  sufiicient. 

What  complications  may  arise,  and  how  should  they  be  treated? 

1.  (Edema  and  swelling  often  accompanied  by  blebs.  Treat  by 
loose  bandaging  at  first,  and  evaporating  lotions  ;  follow  by  pres- 
sure. 

2.  Ulceration  and  sloughing  of  soft  tissues.  Free  ulcerating 
spot  from  pressure  by  careful  padding  of  splint. 

3.  Muscular  spasm.  Treat  by  moderate  pressure,  morphia 
injections,  or  tenotomy. 

4.  Gangrene.  Usually  the  result  of  too  tight  dressing,  or  lace- 
ration of  main  artery.     Relieve  pressure. 

Rarely.  Venous  thrombosis,  embolism,  fat  embolus — causing 
death  by  asphyxia.     Treatment :  cardiac  stimulants. 

How  do  you  treat  compound  fractures  ? 
If  the  external  wound  is  small  and  the  fracture  not  otherwise 


FRACTURES.  109 

complicated,  thoroughly  cleanse  with  bichloride  1  :  1000,  and 
close  with  absorbent  cotton  saturated  in  a  solution  of  ether, 
iodoform,  and  collodion,  equal  parts  of  each.  Splint  as  usual. 
If  inflammatory  symptoms  arise,  or  if  there  be  much  original 
comminution  or  laceration  of  soft  parts,  pick  out  loose  frag- 
ments, thoroughly  cleanse,  irrigate  with  bichloride  solution 
1  :  1000,  drain,  and  apply  antiseptic  dressing,  splinting  as  usual. 
If  wound  be  older  than  twenty-four  hours,  wash  with  1  :  5  car- 
bolic solution  (acid  carbol.  1,  alcohol  5). 

What   complications   arise  in   the  treatment   of  compound 
fractures  ? 
Necrosis,  osteomyelitis,  periostitis,  extensive  sloughing  of  soft 
tissues. 

What  is  the  pathology  of  fracture  ? 

There  is  first  free  hleeding  from  the  vessels  of  the  injured  bone, 
medulla,  and  surrounding  soft  parts.  This  is  followed  by  in- 
flammation with  exudation,  absorption  of  blood  clot,  and  deposit 
of  plastic  lymph  about  the  seat  of  injury.  Organization  completes 
the  process  ;  the  plastic  lymph  is  converted  first  into  cartilage, 
then  into  bone. 

What  is  callus  ? 

Tlie  plastic  lymph  which  is  organized  into  bone  tissue  for  the 
repair  of  fractures. 

How  is  the  callus  disposed  about  a  fracture  ? 

A  portion  is  deposited  as  a  fusiform  swelling  ensheathing  the 
two  broken  bone  ends,  called  ensheathing  callus ;  a  portion  fills  the 
medullary  canal  above  and  below  the  break  acting  as  a  support- 
ing pin,  called  pin  or  central  callus.  A  portion  is  directly  be- 
tween the  broken  surfaces  restoring  their  continuity,  called 
intermediate  or  definitive  callus. 

What  is  meant  by  temporary  and  permanent  callus  ? 

The  ensheathing  and  pin  callus  is  temporary,  being  absorbed 
when  the  bone  is  firmly  united  by  the  intermediate  or  permanent 
callus. 


110  ESSENTIALS    OF    SURGERY. 

What  period  of  time  is  occupied  by  the  various  processes  neces- 
sary for  the  repair  of  fracture  ? 

Absorption  of  clot  first  week,  formation  of  plastic  lymph  and 
beginning  organization  second  week,  ossification  of  the  callus  4 
to  8  weeks,  absorption  of  temporary  callus  one  year. 

What  complications  are  common  to  all  fractures  ? 

Shock. 

Retention  of  urine,  treat  by  catheter. 

Traumatic    delirium,    especially    in    drunkards — sedatives, 
stimulants. 
Hypostatic  congestion  of  lungs. 

What  compound  fractures  require  amputation  ? 

Compound  fractures  associated  with — 

1.  Very  extensive  laceration  of  soft  parts. 

2.  Great  destruction  of  bone  substance. 

3.  Injury  to  the  main  artery  of  leg  or  thigh  (femoral  or  post- 
tibial). 

4.  Injury  to  knee  or  ankle,  if  extensive. 

Define  delayed  union  and  non-union. 

TInio7i  is  delayed  when,  fractures  are  not  firmly  joined  by  callus 
in  4  to  6  weeks. 

We  have  non-union  or  ununited  fracture  when  the  continuity 
of  the  bone  is  not  restored  after  twelve  weeks. 

What  are  the  causes  of  delayed  union  and  non-union? 

1.  Constitutional  include  all  conditions  depressing  to  health 
and  nutrition,  as  acute  fevers,  syphilis,  phthisis,  scurvy,  ne- 
phritis, etc. 

2.  Local,  a.  Undue  mohility  of  fragments  often  from  improper 
splinting  or  meddlesome  interference. 

h.  Separation  of  fragments^  by  muscular  action,  or  by  interpo- 
sition of  soft  parts  or  necrosed  bone, 
c.  Interference,  with  Uood  supply^  as  in  intracapsular  fracture. 

How  do  you  treat  non-union  ? 

Treat  constitutional  conditions. 


FRACTURES.  Ill 

Locally  the  means  adopted  would  be  in  the  order  given  below, 
one  failing  the  next  should  be  tried.  The  object  of  all  these 
methods  is  to  set  up  an  acute  aseptic  inflammation,  which  shall 
provide  sufficient  exudation  for  the  formation  of  healthy  callus. 

1.  Absolute  fixation,  careful  dressing,  plaster  bandage. 

2.  Friction.  Eub  ends  of  bone  together  either  manually  or  by 
getting  patient  up  and  allowing  some  use,  the  fragments  being 
held  in  apposition  by  fixed  plaster  bandage  or  apparatus. 

3.  Brill  fragments  subcutaneously  to  excite  inflammation  and 
deposition  of  plastic  lymph ;  treat  subsequently  by  absolute  fix- 
ation. 

4.  Drill  and  pin  fragments  together  leaving  the  pin  in  place. 

5.  Besection  of  the  ends  of  the  bones,  joining  the  fresh  surfaces 
by  silver  wire.  Drain  thoroughly  and  close  the  wound.  Secure 
fixation  by  careful  splinting. 

Name  the  forms  of  non-union? 

1.  No  union  whatever  between  the  fragments. 

2.  Ligamentous  union. 

3.  False  joint. 

What  is  vicious  union  ? 

Union  accompanied  either  by  great  deformity,  or  by  the  bind- 
ing together  of  bones  which  should  move  on  each  other,  as  the 
radius  and  ulna. 

How  do  you  treat  vicious  union  ? 

If  recent,  restore  immediately  by  force,  or  by  splints  and  pres- 
sure. If  firm  union  has  taken  place,  or  the  fracture  is  not 
amenable  to  other  treatment,  the  bone  should  be  broken  again, 
properly  set,  and  fixed  in  position.  Deformity  from  exuberant 
callus  gradually  disappears.  Should  it  persist,  and  should 
pressure  symptoms  arise,  callus  must  be  cut  away. 

How  do  you  treat  an  injury  which  you  suspect  may  be  a  frac- 
ture? 
Treat  as  a  fracture,  subsidence  of  swelling  will  clear  the  diag- 
nosis. 


112  ESSENTIALS    OF    SURGERY. 

Under  what  circumstances  do  you  use  ansesthetics  in  the  diag- 
nosis and  treatment  of  fracture  ? 

1.  In  case  of  difficulty  or  doubt. 

2.  In  complications  requiring  prolonged  Or  painful  manipu- 
lations. 

3.  Where  reduction  is  not  readily  effected. 

How  do  you  treat  the  swelling  and  ecchymosis  common  to  all 
fractures  ? 

Evaporating  lotions  for  two  or  three  days,  followed  by  care- 
fully guarded  pressure.  Four  ounces  of  alcohol  and  four  drachms 
of  ammonium  muriate,  two  ounces  of  the  solution  of  acetate  of 
lead,  or  eight  ounces  of  laudanum,  to  the  pint  of  water.  Apply 
on  lint  which  must  not  be  covered  with  oiled  silk,  but  kept  con- 
stantly wet  by  the  solution. 

What  is  the  cause  of  the  late  discoloration  in  fractures? 

The  effiised  blood  gradually  works  its  way  to  the  surface,  be- 
tween layers  of  fascia,  in  the  path  of  least  resistance  ;  the  disin- 
tegration of  the  red  corpuscles  causes  the  ecchymosis  or  discolo- 
ration. 

Special  Fractures. 

Describe  fractures  of  the  nasal  bone. 

Cause.     Direct  violence. 

Signs.  Displacement,  backward  or  lateral.  Crepitus.  Un- 
natural mobility.  Deformity.  Yery  rapid  swelling.  Free 
bleeding. 

How  may  this  fracture  be  complicated? 

1.  Profuse  hemorrhage. 

2.  Emphysema  of  surrounding  soft  parts. 

3.  Deflection  or  fracture  of  septum  nasi. 

4.  Injury  to  base  of  brain  through  the  perpendicular  plate  of 
ethmoid. 

Give  the  treatment  of  fracture  of  the  nasal  bone. 

Beduce  at  once  by  pressure  exerted  by  a  director  or  closed 
haemostatic  forceps  passed  into  the  nostril.    Retain  in  place,  if 


FRACTURES.  113 

necessary,  by  packing  the  nostnls  with  iodoform  gauze  or  an 
inflatable  rubber  bag,  the  respiratory  tract  being  kept  open  by 
a  rubber  tube.  If  there  is  much  comminution  and  these  means 
fail, /as/en  the  fragments  together  withpins^  passed  from  the  outside, 
taking  in  the  periosteum.  Inspect  the  nostrils  for  deflection  of 
septum,  which  must  always  be  replaced. 

Check  hemorrhage  by  heat,  cold,  astringents,  or  packing. 

Treat  swelling  by  evaporating  lotions. 

Alicays  reduce  thoroughly. 

Describe  fractures  of  the  superior  maxillary  bones. 
Ordinary  fracture  symptoms,  generally  accompanied  by  great 

swelling. 

Common  seat  of  fracture,  alveolar  process — at  times  nasal  pro- 
cess, malar  process,  or  body  of  maxilla.  The  anterior  wall  of 
the  antrum  may  be  driven  in. 

How  do  you  treat  fractures  of  the  superior  maxilla? 

Eeduce,  if  deformity.  If  the  bone  is  driven  in,  raise  by  pres- 
sure applied  from  the  mouth,  or  by  means  of  an  elevator  passed 
through  a  small  skin  wound.  Ketain  alveolar  process  by  making 
the  lower  jaw  the  splint,  applying  a  Barton's  bandage  ;  treat 
swelling  and  inflammation  by  evaporating  lotion,  applied  on  lint 
(alcohol  and  water  equal  parts). 

Describe  fractures  of  the  inferior  maxilla. 

Usual  seat.     Near  or  through  the  anterior  mental  foramen.    - 
Fractures  also  occur  at  the  symphysis ;  through  any  part  of 
the  hody ;  through  the  ramus;  through  the  condyloid  process; 
through  the  coronoid  process. 

These  fractures  are  often  compound,  from  rupture  of  the  mu- 
cous membrane. 

Give  the  symptoms  of  fracture  of  the  inferior  maxilla. 

Body.  The  cardinal  signs  of  fracture,  together  with  pain, 
swelling,  dribbling  of  saliva,  disability.  The  central  portion  of 
the  bone  is  pulled  downward  and  backward  by  the  digastric, 
geniohyoid,  and  geniohyoglossus  muscles. 

Fractures  of  the  ramus  give  little  deformity,  the  bone  being  held 
8 


114  ESSENTIALS    OF    SURGERY. 

in  place  by  the  masseter  without,  the  internal  pterygoid  within. 
Manipulation  elicits  mobility  and  crepitus. 

In  fractures  of  the  neck,  the  condyle  is  pulled  forward  and  in- 
ward by  the  external  pterygoid,  causing  great  pain  and  crepitus 
on  opening  or  closing  the  mouth. 

Give  the  treatment  for  fracture  of  the  inferior  maxilla. 

Careful  reduction  and  the  application  of  a  moulded  pasteboard 
splint,  well  padded  with  cotton,  and  held  in  place  by  a  Barton's 
or  Gibson's  bandage.  Frequently  wash  the  mouth  with  satu- 
rated solution  of  boracic  acid. 

If  the  dressing  fails  to  keep  the  fragments  in  proper  position, 
they  should  be  drilled  and  wired  in  place.  The  dressing  can  be 
removed  in  five  weeks. 

Give  the  symptoms  of  fracture  of  the  hyoid  bone. 

Seat  of  injury.  Greater  horn.  Pain  on  eating  or  speaking, 
together  with  the  cardinal  signs  of  fracture,  elicited  by  exami- 
ning with  the  fingers  of  one  hand  in  the  pharynx,  while  the  other 
hand  outlines  the  bone  from  without.  The  displacing  factor  is 
the  middle  constrictor. 

Give  the  treatment  for  fractures  of  the  hyoid  bone. 

Reduce  by  pressure,  keep  the  head  between  flexion  and  exten- 
sion, support  by  a  pasteboard  collar,  give  nutrient  enemata  for 
four  days,  then,  if  dysphagia  be  still  great,  feed  by  the  oesopha- 
geal tube. 

Give  the  symptoms  of  fracture  of  the  laryngeal  cartilages. 

Usual  seat.  Thyroid  cartilage.  Symptoms — Aphonia,  dys- 
pnoea^ and  bloody  expectoration,  together  with  emphysema^  deform- 
ity, and  possibly  moist  crepitus. 

Treatment.  On  the  appearance  of  dyspnoea,  intubation,  or, 
that  failing,  tracheotomy.  Feed  by  rectum  for  some  days,  and 
secure  absolute  rest  to  the  parts. 

Despribe  fractures  of  the  clavicle. 

Cause.  Usually  indirect  violence,  as  falls  on  the  palm  of  the 
hand. 

Seat.  May  be  any  portion  of  the  bone,  generally  outer  portion 
of  middle  third. 


FRACTURES.  115 

Direction.    Oblique. 

Dis2jlacement.  Shoulder  falls  downward,  forward,  and  inward, 
shortening  detected  by  measurement  from  middle  of  upper 
border  of  sternum  to  coracoid  process. 

What  causes  the  displacement  in  fractured  clavicle? 

The  outer  fragment  drops  downward,  inward,  and  forward 
from  the  weight  of  the  shoulder,  and  the  action  of  the  two  pecto- 
rals, the  latissimus  dorsi  and  the  serratus  magnus  ;  the  inner 
extremity  of  the  outer  fragment  is  thrown  somewhat  backward 
by  the  rhomboidei  and  levator  anguli  scapuli,  so  that  it  lies 
behind  and  below  the  outer  extremity  of  the  inner  fragment, 
which  is  shghtly  tilted  up  by  the  sterno-cleido  mastoid. 

Give  the  symptoms  of  fractured  clavicle. 

Crepitus  and  preternatural  mobility  readily  elicited  by  pushing 
up  and  rotating  the  humerus. 

Deformity  detected  by  passing  the  finger  along  the  subcutane- 
ous surface  of  the  bone,  by  inspection,  by  measurement ;  shoulder 
flattened,  arm  disabled. 

Fractures  of  acromial  and  sternal  end  necessarily  allow  of  but 
little  displacement.  If  external  to  conoid  and  trapezoid  liga- 
ments, there  is  marked  displacement  of  the  outer  fragment. 

Give  the  treatment  for  fractured  clavicle. 

The  object  of  the  treatment  is  to  restore  the  fragments  to  their 
proper  position  by  forcing  the  shoulder  upward,  outward,  and 
"backward.     This  is  accomplished  by — 

1.  Sayer^s  dressing.  Strips  of  adhesive  plaster  three  and  one- 
half  inches  wide.  The  first  is  long  enough  to  surround  the  body 
including  the  arm.  This  strip  encircles  the  arm  over  the  inser- 
tion of  the  deltoid  in  the  form  of  a  loosely  fitting  loop,  which  nmst 
be  made  secure  by  sewing.  Draw  the  arm  somewhat  down- 
ward and  backward,  to  make  tense  the  clavicular  origin  of  the 
pectoralis  major,  and  fasten  it  in  this  position  by  carrying  the 
strip  entirely  around  the  body  securing  it  to  itself  in  the  back. 

The  second  strip  begins  at  the  sound  shoulder,  is  carried  ob- 
liquely over  the  back  to  the  elbow  of  the  injured  side,  which  is 
received  in  a  slit  provided  for  the  purpose,  it  is  then  carried 


116 


ESSENTIALS    OF    SURGERY. 


upward  across  the  front  of  the  chest  to  its  point  of  origin.  This 
forces  the  shoulder  upward,  backward,  and,  by  pulling  the  elbow 
in,  also  outward. 


Fig.  9. 


Fig.  11. 


2.  The  recumbent  posture^  supine,  with  the  arm  carried  across 
the  chest,  is  the  best  theoretical  treatment  for  this  injury. 

3.  VelpeaiCs  dressing.  A  pad  fastened  in  the  axilla  of  the  in- 
jured side.  The  forearm  flexed  on  the  arm  and  carried  across  the 
chest  till  the  hand  rests  on  or  near  the  sound  shoulder.  Careful 
manipulation  of  the  fragments  into  proper  position,  and  the  ap- 
plication of  Yelpeau's  bandage. 

4.  DSsaulVs  dressing.  A  pad  fixed  in  the  axilla  by  the  first 
roller.  The  arm  bound  to  the  side  by  the  second  roller.  The 
shoulder  pressed  upward  and  backward  by  the  third  roller. 

Union  in  about  four  weeks  ;  carry  the  arm  in  a  sling  for  one 
or  two  weeks  longer. 

Describe  fractures  of  the  scapula. 

Cause  of  fracture.     Direct  violence. 

Seats  of  fracture  through  1.  Body  or  inferior  angle.  2.  Surgical 
neck  (supra-scapular  notch).  3.  Glenoid  cavity.  4.  Acromion 
or  coracoid  processes. 

What  are  the  symptoms  of  fractured  scapula? 

In  all  situations  there  are  found  disability,  pain,  swelling,  crepi- 
tus, and  preternatural  mobility. 


FRACTURES 


117 


Neck  (through  suprascapular  notch).  DisabiUty  complete. 
If  conoid  and  trapezoid  hgaments  are  torn  there  will  be  a  space 
between  the  acromion  and  humerus — disappearing  on  pressing 
the  arm  upward,  but  recurring  again  when  the  support  is 
removed.  Coracoid  process  moves  with  humerus,  the  acromion 
remains  fixed. 

Acromion  process.  If  behind  the  acromio-clavicular  articula- 
tion the  shoulder  is  flattened,  and  drops  downward,  forward, 
and  inward.     Crepitus  and  undue  mobility. 

Coracoid  process.  Complete  disability.  Unnatural  motion 
may  be  felt  by  pressing  a  finger  deeply  in  the  region  of  this  pro- 
cess and  pushing  up  the  elbow. 

Give  the  treatment  for  fractures  of  the  scapula. 

Body.  Compress  to  both  borders  of  the  scapula,  adhesive 
plaster  extending  circularly  from  the  spine  to  the  sternum, 
Yelpeau  or  Desault  bandage,  with  the  arm  vertically  to  the  side. 

JVecfc,  glenoid  cavity^  acromion  or  cora- 
coid process.    Towel  in  axilla,  and  Vel-  ^^* 
peau  or  Desault  bandage. 

Describe  fractures  of  the  humerus. 

Muscular  attachments. 

To  greater   tuberosity.      Supraspina- 
tus,  infraspinatus,  and  teres  minor. 

To  lesser  tuberosity.  Subscapularis. 
Anterior  bicipntal  ridge.  Pectoralis 
major.  Posterior  bicipital  ridge.  La- 
tissimus  dorsi,  teres  major.  Sliaft. 
Coraco-brachialis,  deltoid,  triceps.  In- 
ternal condyle.  Pronator  radii  teres  and 
common  flexor  tendon.  External  con- 
dyle and  condyloid  ridge.  The  two  supi- 
nators, anconeus,  extensor  carpi  radialis  longior,  and  the  com- 
mon extensor  tendon. 

There  may  be  fractures  of  the  head,  anatomical  neck,  tuber- 
osities, surgical  neck,  including  epiphysis,  shaft ;  there  may  be 
supra-condyloid,  inter-condyloid,  T  or  comminuted,  condyloid, 
epicondyloid  (internal  only)  fractures. 


Comminuted  or  T  fracture. 


118  ESSENTIALS    OF    SURGERY- 

Give  the  symptoms  of  fractured  humerus. 

In  all,  except  the  impacted  fractures  of  the  anatomical  neck, 
there  are  pain,  crepitus,  preternatural  mobility,  deformity,  dis- 
ability, and  swelling. 

Head  and  anatomical  neck.  Symptoms  obscure,  slight  short- 
ening, crepitus  on  upward  pressure  and  rotation,  broken  ex- 
tremity may  be  felt  in  axilla. 

Greater  tuberosity.  Depression  under  acromion  process,  widen- 
ing of  shoulder,  smooth  bony  prominence  (head  of  bone)  under 
coracoid,  crepitus  on  rotation  and  pressing  tubercles  together, 
external  rotation  cannot  be  performed  by  the  patient. 

Surgical  necJc.  (That  portion  of  the  shaft  of  the  humerus  lying 
between  the  tuberosities  and  the  insertion  of  the  latissimus 
dorsi  and  teres  major  muscles.)  Commonest  seat  of  fracture. 
Direction  transverse.  Shortening  (measured  between  acromion 
process  and  external  condyle).  Lower  fragment  drawn  inward 
and  forward  by  latissimus  dorsi,  pectoralis  major,  and  teres 
major,  pulled  upward  by  deltoid,  biceps,  triceps,  and  coraco- 
brachialis.  Rough  end  of  lower  fragment  felt  near  coracoid 
process.  Unnatural  mobility  and  crepitus  on  extension  and 
rotation. 

JEpiphyseal.  As  in  surgical  neck,  except  that  it  occurs  in 
young  people,  and  that  the  crepitus  is  moist  and  the  fragments 
smooth. 

Shaft  of  humerus.  Mostly  below  middle  third.  Direction 
oblique.  Deformity^  overlapping,  from  biceps  and  triceps ;  if 
above  insertion  of  the  deltoid  the  lower  fragment  is  pulled  out- 
ward by  that  muscle  ;  if  below,  the  upper  fragment  is  tilted  for- 
ward.    Cardinal  signs  of  fracture  readily  detected. 

Supra-condyloid.  Projection  in  front  and  behind.  That  in 
front  is  due  to  the  rough  end  of  the  upper  fragment ;  that 
behind  is  due  to  the  condyles  and  olecranon  occupying  their 
normal  relation  in  regard  to  each  other.  Shortening  between 
acromion  process  and  external  condyle.  Reduction  easy,  but 
deformity  promptly  recurs. 

Intercondyloid.  Increased  breadth  between  the  condyles,  and 
crepitus  elicited  by  pressing  and  rubbing  them  together. 


FRACTURES. 


119 


Condyloid.  Crepitus  and  mobility  on  manipulating  the  bony 
prominences,  displacement  slight. 

All  fractures  about  the  elbow-joint  are  accompanied  by  great 
and  rapid  swelling. 


Fig.  13. 


Fig.  14. 


Fracture  of  the  lower  extremity 
of  the  humerus. 


Dressing  for  fracture  of  the  upper 
third  of  the  humerus. 


Give  the  treatment  for  fractures  of  the  humerus. 

Upper  extremity.  Including  intra-  and  extra-capsular,  trochan- 
teric, and  fractures  of  the  surgical  neck. 

Fasten  a  folded  towel  in  the  axilla  by  a  bandage  and  adhesive 
strap. 

Flex  the  arm,  and  carry  the  elbow  slightly  forward,  apply  a 
spiral  reversed  from  the  hand  to  the  seat  of  fracture.  Place  a 
moulded  pasteboard  cap,  or  three  straight,  narrow,  external 
splints,  reaching  from  the  acromion  process  to  the  external 
condyle,  upon  the  outer  aspect  of  the  arm  and  shoulder,  bind 
in  place  by  a  few  circular  turns  of  a  roller,  and  complete  the 
dressing  by  fastening  the  arm  to  the  side,  and  slinging  the  fore- 
arm at  the  wrist. 


120 


ESSENTIALS    OF    SURGERY. 


Shaft  of  humerus.  Primary  roller  up  to  the  seat  of  fracture, 
well  padded  internal  angular  splint,  avoiding  pressure  upon 
internal  condyle,  shoulder  cap  extending  to  external  condyle 
or  below  on  forearm,  arm  bound  to  the  side  by  circular  turns 
of  the  roller,  and  slung  at  the  wrist. 

If  obstinate  deformity  from  outward  tilting  by  the  deltoid, 
relax  by  dressing  in  the  abducted  position  for  a  few  days. 


Anterior  angular  splints. 


Supra-condyloid.      Internal    angular  and    external  moulded 
splint,  or  anterior  angular  splint  and  posterior  moulded  trough. 
Condyloid.     Yery  obtuse  angled,  anterior,  or  internal  splint. 

What  complications  may  arise  in  the  treatment  of  these  frac- 
tures ? 

1.  Non-union,  always  in  intracapsular  fractures,  frequently 
in  fractures  of  the  shaft. 

2.  Paralysis,  from  injury  to  the  musculo-spiral  or  ulnar  nerves. 

3.  Anchylosis,  from  inflammation  within  or  about  the  joints, 
particularly  the  elbow. 


FRACTURES.  121 

How  do  you  avoid  anchylosis  in  fractures  about  the  joints  ? 

By  practising  passive  motion.  Begin  in  four  weeks  for  the 
shoulder-joint ;  one  week  for  the  elbow.  Promptly  treat  inflam- 
mation by  cold,  local  depletion,  aspiration  at  times,  and  pressure. 

How  long  do  you  continue  treatment  ? 

Five  to  eight  weeks,  replacing  the  splints  with  a  sling  in  that 
time. 

What  fractures  occur  in  the  ulna  ? 

Seats  of  fractures :  shaft,  olecranon,  styloid  or  coronoid  pro- 
cesses. 

Cause,  direct  or  indirect  violence.     Usual  seat  lower  third. 

Give  the  symptoms  of  fractured  ulna. 

Cardinal  symptoms  as  in  all  fractures. 

Shaft,  being  subcutaneous,  deformity,  crepitus  and  undue 
mobility  readily  recognized. 

Olecranon.  Loss  of  power  to  extend,  undue  mobility  ;  crepitus 
on  extending  forearm  and  pressing  olecranon  in  position.  Dis- 
placement often  very  slight.  If  aponeurosis  is  torn  through, 
the  process  is  drawn  well  up  the  arm  from  between  the  condyles, 
leaving  a  perceptible  gap. 

Coronoid  process.  Yery  rare.  Tendency  to  backward  luxation 
of  ulna,  movable  bony  prominence  in  front. 

Styloid  process.  Mobility.  Crepitus  detected  by  carrying 
hand  towards  radial  border. 

Give  the  treatment  for  fractures  of  the  ulna. 

Olecranon.  •  Figure-of-eight  about  the  joint,  the  upper  segment 
looping  behind  the  displaced  fragment,  pulling  it  downward. 
Application  of  a  very  obtuse  anterior  or  internal  angular  splint. 

Shaft.  Two  well  padded  splints,  each  wider  than  the  forearm, 
one  reaching  from  the  internal  condyle  to  the  tips  of  the  fingers, 
the  other  from  the  external  condyle  to  the  metacarpo-phalangeal 
articulation.  Reduce  the  fracture,  apply  splints,  with  the  hand 
midway  between  pronation  and  supination.  Support  the  fore- 
arm through  its  whole  extent  by  a  handkerchief. 


122 


ESSENTIALS    OF    SUKGERY, 


Coronoid  process.      Anterior  angular  splint  and  compress. 
Passive  motion  in  three  weeks. 

Fig.  16. 


Dressing  for  fractures  of  one  or  both  bones  of  the  forearm.  . 

Styloid  process.  Keduce,  apply  a  compress.  Bandage  to  a 
Bond  splint,  or  apply  anterior  and  posterior  straight  splints. 

Describe  fractures  of  the  radius. 

Seats  of  fracture.  Head,  neck,  shaft,  lower  extremity.  Ordi- 
nary seat,  lower  extremity. 

Muscular  attachments.  Biceps,  supinator  brevis,  pronator 
radii  teres,  pronator  quadratus.  supinator  longus. 

What  fractures  occur  at  the  lower  extremity  of  the  radius  ? 

Barton'' s  (rare).  A  chipping  off  of  the  posterior  lip  of  the 
articular  surface. 

Colles''s.  Common.  A  transverse  break  ^  inch  to  1^  inches 
above  the  joint. 

Smith''s.  A  transverse  fracture  1^  inches  to  2^  inches  above 
the  joint. 


FRACTURES.  123 

Fig.  17. 


Give  the  symptoms  of  fractured  radius. 

Cause.     Fall  on  the  palm  of  the  hand.     Direct  violence. 

Lower  extremity.  Silver  fork  deformity.  Lower  fragment  lies 
posterior  to  the  upper  fragment.  Hand  carried  towards  radial 
side  by  supinator  longus,  extensor  carpi  radialis,  and  extensors 
of  the  thumb.  Crepitus  and  mobility  on  rotation.  All  symp- 
toms marked. 

Shaft.  Upper  fragment  slightly  tilted  forward  by  biceps, 
and,  if  above  insertion  of  pronator  radii  teres  (middle  third), 
supinated  by  biceps  and  supinator  brevis.  Lower  fragment  pro- 
nated  by  two  pronator  muscles,  tilted  towards  ulna  by  pronator 
quadratus  and  supinator  longus.  If  below  the  insertion  of  the 
pronator  radii  teres,  deformity  as  before,  except  that  both  frag- 
ments are  midway  betweeu  pronation  and  supination.  Crepitus 
and  mobility  elicited  by  rotation. 

Neck  of  radius.  Upper  fragment  supinated  by  short  supinator, 
lower  fragment  pulled  forward  by  biceps.  Crepitus,  mobility, 
and  deformity  detected  by  pressing  the  thumb  into  the  bend  of 
the  elbow  and  rotating  the  forearm. 

Both  bones.  Usual  seat  lower  third.  Shortening  and  angular- 
ity often  marked.  Crepitus,  unnatural  mobility  by  grasping  the 
bones  on  either  side  of  the  fracture  and  manipulating,  or  by 
placing  the  thumb  upon  the  head  of  the  radius,  making  exten- 
sion, and  rotating. 

Upper  fragments  pulled  forward  by  biceps,  brachialis  anticus, 
and  pronator  radii  teres.  Lower  fragments  approximated  by 
pronator  quadratus  ;  overlapping  from  the  action  of  the  flexors 
and  extensors. 


124  ESSENTIALS    OF    SURGERY. 

How  do  you  treat  fractures  of  the  radius  ? 

Neck.  Anterior  angular  splint,  and  compress  over  upper  end 
of  displaced  shaft.     Dress  in  supination. 

Shaft.  As  for  shaft  of  ulna.  Reduce  by  extension,  counter- 
extension,  manipulation. 

Lower  extremity.  Reduction  most  important.  Fragments 
once  placed  in  proper  jDosition  usually  remain  so. 

Fig.  18. 


Bond's  splint. 

Reduce  thoroughly  by  extension,  pressure,  and  manipulation. 
Apply  a  Levis  or  a  Bond  splint,  or  simply  circular  strips  of 
adhesive  plaster.  In  all  cases  leave  the  fingers  free,  and  en- 
couraging their  use.  The  Bond  splint  requires  two  pyramidal 
pads,  the  base  of  the  posterior  one  to  go  over  the  upper  extremity 
of  the  lower  fragment,  the  apex  pointing  toward  the  fingers. 
The  base  of  the  anterior  one  to  go  under  the  lower  extremity  of 
the  upper  fragment,  the  apex  pointing  toward  the  elbow.  Firm 
union  in  five  to  seven  weeks. 

Fractures  of  both  hones.,  or  shaft  of  either^  including  Colles's  frac- 
ture, complicated  by  a  fracture  of  the  styloid  process  of  the  ulna. 

Two  straight  splints  wider  than  the  forearm,  as  in  fractures 
of  the  shaft  of  the  ulna. 

Sling  all  fractures  of  the  forearm  by  means  of  a  handkerchief 
supporting  it  throughout  its  entire  extent. 

"What  forearm  fractures  are  dressed  in  supination  ? 

Dress  fractures  above  the  insertion  of  the  pronator  radii 
teres  with  the  palm  up ;  in  all  other  fractures,  dress  with  the 
thumb  up  (midway  between  pronation  and  supination). 


FRACTURES.  125 

Describe  fractures  of  the  metacarpus. 

Usually  second  or  fifth.  Posterior  angular  projection,  from 
distal  end  of  bone  being  pulled  forward  by  the  flexors.  Crepitus 
and  mobility  elicited  by  seizing  and  manipulating  the  two  ex- 
tremities of  the  bone. 

Give  the  treatment  for  fractures  of  the  metacarpus. 

Treat  by  an  anterior  splint  to  the  hand  and  forearm,  padding 
well  to  preserve  the  concavity  of  the  j)alm.  Compress  poste- 
riorly if  any  tendency  to  deformity.  Retain  the  dressing  for  five 
weeks.     Passive  motion  in  three  days. 

Describe  fractures  of  the  phalanges. 

Rare.  Due  to  direct  force  ;  readily  diagnosed  by  manipulating 
the  finger  bones.  Treat  by  anterior  moulded,  posterior  straight 
splint,  extending  to  the  wrist.  A  long  palmar  splint  may  be 
used. 

Describe  fractures  of  the  pelvis. 

Cause.     Great  and  direct  violence. 

Seats.  Crest  of  ilium,  basin  of  pelvis,  acetabulum,  sacrum, 
or  coccyx. 

Symptoms.  In  all  these  fractures  there  is  a  sense  of  falling 
apart. 

Crest.  Patient  leans  toward  the  afiected  side  ;  crepitus  and 
mobility  on  grasping  and  manipulating  the  bone.  External 
evidence  of  injury,  discoloration,  swelling,  etc. 

Pelvic  hasin.  Crepitus  and  mobility  may  be  elicited  by  grasp- 
ing the  iliac  spines  and  attempting  to  move  them  in  opposite 
directions  ;  great  pain,  and  inability  to  sit  or  stand  ;  often  a 
line  of  ecchymosis  along  Poupart's  ligament  and  the  crest  of 
the  iHum.  Examination  per  rectum  or  vagina  may  reveal  dis- 
placement or  crepitus. 

Acetabulum.  Either  the  floor  or  the  rim  may  be  fractured  ; 
caused  by  blows  on  the  trochanter. 

Floor.  Great  pain  on  attempting  to  stand,  or  in  any  way 
moving  the  femur  ;  crepitus  best  detected  by  thrusting  the  femur 
directly  upward  ;  very  slight  shortening. 

liira.     Usually  the  upper  and  posterior  part  is  broken  off. 


126  ESSENTIALS    OF    SURGERY. 

Subluxation  of  femur  backward.  On  circumduction,  the  head 
of  the  bone  can  be  felt  to  slip  out  at  a  certain  point,  returning  to 
its  proper  position  as  the  motion  is  continued  ;  there  is  crepitus. 
Sacrum  and  coccyx.  Direction  transverse.  Cause,  direct  vio- 
lence. There  may  be  some  anterior  projection  from  the  action 
of  the  coccygeus  and  levator  ani  muscles.  Crepitus  and  mobility, 
detected  by  a  finger  in  the  rectum.     Pain  on  defecation. 

How  are  these  fractures  treated  ? 

Place  the  patient  on  a  fracture  bed,  i.  e.,  a  firm,  hard,  evenly 
padded  bed,  with  a  central  perforation  through  which  the  con- 
tents of  the  bowel  may  be  passed  without  moving  the  patient. 
Apply  a  broad  bandage  or  binder  tightly  about  the  pelvis  ;  tie 
the  knees  together.  The  most  comfortable  position  is  usually 
on  the  back,  with  the  thighs  and  knees  flexed,  and  supported  by 
pillows ;  allow  the  patient  to  assume  the  position  of  his  choice. 
If  there  is  displacement  of  the  coccyx,  pack  the  rectum  with 
iodoform  gauze  or  an  inflated  rubber  bag. 

Fractures  of  the  acetabulum  are  treated  by  extension,  and 
sand  bags  or  splints,  as  fractures  of  the  femur. 

Describe  fractures  of  the  femur. 

Muscular  attachment — 

To  greater  trochanter — Two  gluteals  (medius  and  minimus),  two 
obturators,  two  gemelli,  pyriformis,  quadratus  femoris.  All  ex- 
ternal rotators  except  the.  glutei. 

Lesser  trochanter — Psoas,  iliacus  (below),  both  flexors  and  ex- 
ternal rotators. 

Condyles — Gastrocnemius,  plantaris,  and  popliteus. 

Seats  of  fracture.     Neck — Intracapsular,  extracapsular,  mixed. 

Shaft.  Loicer  extremity — Supracondyloid,  intereondyloid,  T 
or  comminuted,  and  condyloid. 

Give  the  symptoms  of  intracapsular  fracture  of  femur. 

Occurs  in  aged  people,  frequently  females,  from  slight  violence. 
Hip  flattened,  trochanter  less  prominent,  and  lying  nearer  to 
the  anterior  superior  spinous  process  of  the  ilium,  with  its  upper 
border  above  Nelaton's  line  (a  line  from  the  anterior  superior 
iliac  sp^gi  to  the  tuberosity  of  the  ischium). 


FRACTURES.  127 

Crepitus  elicited  by  pressure  upon  the  trochanter,  and  making 
traction  and  internal  rotation.  Pain  on  motion.  Preternatural 
mobility,  foot  can  be  everted  till  the  heel  looks  directly  upward. 
Swelling  not  accompanied  by  marked  ecchymosis.  Shortening 
from  ^  to  1^  inches  ;  may  be  slight  at  first  and  progressively 
increase.     Loss  of  power. 

Fig.  20. 


Lines  of  fracture  of  the  upper  extremity  Intracapsular  fracture  of 

of  the  femur.  the  neck  of  the  femur. 

Give  the  symptoms  of  extracapsular  fracture  of  the  femur. 

Cause.  Considerable  direct  violence.  It  occurs  in  middle- 
aged  males,  with  well-marked  external  evidence  of  injury,  i.  e., 
swelling  and  discoloration. 

Crepitus  distinct,  harsh,  readily  elicited. 

Shortening  marked,  1  to  2|-  inches. 

Give  the  symptoms  of  impacted  fracture  of  the  hip  joint. 

The  impacted  fracture  may  be  either  intra-  or  extracapsular. 
There  will  be  :  1.  No  crepitus.  2.  Slight  shortening,  not  dis- 
appearing on  traction.  3.  Loss  of  function  in  the  limb,  but  not 
absolute.     4.  Evidence  of  much  injury  to  the  soft  parts/ 

The  foot  may  be  inverted  or  everted. 


128  ESSENTIALS    OF    SURGERY. 

Give  the  symptoms  of  fracture  of  the  great  trochanter. 

This  injury  often  accompanies  extracapsular  fracture,  but  may- 
exist  alone.  Cause.  Direct  violence.  It  is  characterized  by 
pain,  swelling,  discoloration,  and  crepitus.  Unnatural  mobility 
elicited  by  pressing  into  place  the  broken  fragment,  whicn  may 
be  felt  as  a  hard  lump  upon  the  dorsum  of  the  ilium. 

Give  the  symptoms  of  fracture  of  the  shaft  of  the  femur. 

Cause. .  Direct  violence. 

Common  seat.     Middle  third.     Direction  Oblique. 

E  version  of  foot,  very  marked  ;  shortening,  increased  mobility, 
crepitus,  loss  of  power.  Upper  fragment,  especially  in  the  upper 
third,  drawn  forward  and  everted  by  psoas,  iliacus,  and  external 
rotators ;  lower  fragment  pulled  up  and  in  by  adductors,  flexors, 
and  extensors.  , 

Give  the  symptoms  of  fracture  of  the  lower  extremity  of  the 
femur. 

Supracondyloid.  Lower  fragment  pulled  back  by  gastrocne- 
mius, shortening,  and  eversion. 

Intercondyloid,  condyloid^  or  T  {transverse  and  intercondyloid). 
Increased  measurement  between  the  condyles,  associated  with 
great  and  rapid  swelling  of  the  knee.     Undue  mobility  and 

Fig.  21. 


Extension  applied  for  fracture  of  the  femur. 


crepitus,  elicited  by  bending  the  knee,  or  by  grasping  the  con- 
dyles and  pushing  them  in  opposite  directions.  Very  great 
pain. 


FRACTURES, 


129 


How  do  you  treat  fractures  of  the  femur  ? 

Upper  extremity  and  shaft.  Extension  by  adhesive  plaster  2^ 
inches  wide  and  long  enough  to  extend  from  the  upper  end  of 
the  lower  fragment,  on  both  sides  of  the  limb,  and  leave  a  4  to  6 
inch  loop  hanging  free  below  the  sole  of  the  foot ;  in  this  loop  is 
laid  a  piece  of  thin  splint  board  2^  inches  wide,  and  so  long,  that 
when  traction  is  made,  the  plaster  will  stand  free  from  the 
malleoli.  This  board  is  fastened  in  place,  and  through  a  hole 
in  its  centre  a  cord  or  bandage  is  passed.  The  adhesive  plaster 
is  placed  along  the  inner  and  outer  aspect  of  the  limb  up  to  the 
seat  of  fracture,  and  secured  in  place  by  a  few  strips  carried 
around  the  limb,  and  a  neatly  applied  spiral  reversed  bandage 
of  the  lower  extremity.     After  an  hour  or  two  the  plaster  is 

Fig.  22. 


Dressing  for  fractured  femur. 


tightly  adherent,  when  the  extending  cord  is  carried  over  a 
pulley,  a  weight  is  attached,  and  a  pad  of  oakum  is  put  beneath 
the  tendo  Achillis.  A  sand-bag,  or  a  bran-bag  and  straight 
splint  is  placed  on  each  side  of  the  leg,  the  inner  extending  from 
the  sole  to  the  perineum,  the  outer  from  the  sole  to  the  axilla, 
and  the  foot  of  the  bed  is  raised  two  to  four  inches  to  provide  for 
counter-extension.  The  position  of  the  foot  is  slight  eversion, 
and  flexion.  The  inner  borders  of  the  inner  malleolus,  internal 
condyle,  and  ball  of  the  great  toe  should  lie  nearly  in  the  same 
vertical  plane,  the  great  toe  pointing  directly  upward. 

Fractures  of  the.  upper  extremity  or  shaft  of  the  femur  may 
also  be  treated  by  well-padded  straight  internal  and  external 


130  ESSENTIALS    OF    SURGERY. 

splints.  The  shaft  may  be  treated  by  plaster  or  other  fixed 
bandage,  or  by  straight  short  splints  buckled  about  the  seat  of 
fracture.  In  all  cases,  except  in  impacted  fracture,  extension 
should  be  used. 

What  dressing  should  be  applied  when  the  upper  fragment  pro- 
jects anteriorly  ? 
Eelax  the  psoas  and  iliacus  by  flexing  the  thigh  and  support- 
ing it  and  the  leg  upon  a  double  inclined  plane,  raise  to  such  an 
angle  that  the  deformity  is  corrected.  Apply  the  extension 
plaster  from  the  knee  to  the  upper  end  of  the  lower  fragment, 
make  a  stirrup  as  before,  then  carry  the  extending  cord  over 
a  pulley,  so  elevated  that  traction  is  made  in  the  long  axis  of  the 
femur. 

Give  the  treatment  for  fractures  of  the  great  trochanter. 

A  bandage  about  the  hips  with  a  moulded  cap  to  keep  the 
trochanter  in  position,  and  a  long  straight  external  splint  ex- 
tending from  the  axilla  to  sole. 

How  do  you  treat  fracture  of  the  lower  extremity  of  the  femur  ? 

If  there  is  obstinate  angular  deformity,  section  of  tendo 
Achillis.  If  marked  shortening,  extension  as  before,  carried 
not  quite  up  to  the  seat  of  fracture.  A  splint,  or  long  fracture- 
box,  well  padded  with  pillows,  should  be  used.  Evaporating 
lotions,  or  aspiration,  for  accompanying  synovitis. 

How  long^  should  treatment  be  continued  in  fractures  of  the 
femur  ? 
Treatment^  five  to  eight  weeks.  Passive  motion  of  the  knee 
joint  after  fourteen  days.  Massage  before  allowing  the  patient 
to  put  the  leg  down.  Application  of  plaster,  or  other  fixed 
dressing  about  the  fracture,  before  walking  is  allowed. 

How  do  you  treat  fracture  of  the  femur  in  infants  ? 

Reduce  by  extension,  counter-extension,  manipulation.  Place 
in  position  a  carefully  padded  external  splint  extending  from 
the  axilla  to  the  sole  of  the  foot,  and  fasten  it  in  place  by  a 
sihca  or  plaster  dressing.     Treatment  for  four  weeks. 


FRACTURES.  131 

How  do  you  distinguish  between  intracapsular  and  extracap- 
sular fractures  of  the  femur  ? 

In  extracapsular — 

1.  Crepitus  is  rougher,  more  readily  elicited,  and  feels  as 
though  immediately  beneath  the  fingers  of  the  surgeon. 

2.  Swelling  and  discoloration  are  greater  and  more  immediate. 

3.  Deformity  or  shortening  is  more  marked,  but  eversion  can- 
not be  carried  so  far  as  in  intracapsular  fracture. 

4.  On  rotation  the  trochanter  is  found  to  pass  through  an  arc 
of  less  radius  in  extracapsular  fractures. 

Describe  fractures  of  the  patella. 

Causes.     Direct  violence,  and  muscular  action. 

Direction.     Transverse   or  longitudinal.     Generally,  but  not 
always,  marked  separation  of  fragments. 
Give  the  symptoms  of  fractured  patella. 

Power  of  extension  lost.  Gap  between  fragments,  increased 
on  flexion.  Great  swelling.  In  longitudinal  fractures,  crepitus 
and  mobility  on  grasping  the  two  sides  of  the  bone  and  pressing 
in  opposite  directions. 

How  do  you  treat  fractures  of  the  patella  ? 

If  there  is  not  much  separation,  elevate  and  apply  a  straight 
posterior  splint  to  the  thigh  and  leg.  If  great  swelling,  cold  and 
evaporating  lotions  for  one  or  two  days,  aspirating  the  joint  if 
necessary.  The  posterior  straight  splint  is  provided  with  lateral 
pegs  and  ratchets,  to  which  are  attached  stripr.  of  adhesive 
plaster  which  are  looped  over  the  upper  and  lower  fragments  ; 
by  turning  these  pegs,  the  lower  fragment  is  steadied,  and  the 
upper  fragment  is  drawn  down  in  position.  Fix  the  lower 
fragment  first,  then  the  upper.  Imbricate  the  plaster  strips 
from  above  downward.  If  the  edges  of  the  fragments  tilt  for- 
ward, carry  a  piece  of  strapping  transversely  around  the  limb. 
Complete  the  dressing  with  a  figure-of-eight  bandage.  Begin 
passive  motion  in  two  or  three  weeks.  Continue  the  splint  for 
six  or  eight  weeks.  Follow  with  a  stiff  bandage,  plaster  or 
glass,  and  keep  the  patient  on  crutches  for  several  months. 

These  fractures  may  also  be  treated  by  Malgaigne's  hooks 
applied  under  strict  antiseptic  precautions.     Or  by  making  a 


132 


ESSENTIALS    OF    SURGERY. 


transverse  incision,  clearing  the  breach  between  the  fragments 
and  the  knee  joint  of  all  clots  or  blood,  drilling  the  fragments 
obliquely  (sparing  the  cartilage),  and  wiring  them  in  close  con- 
tact. 

Fig.  23.  Give  the  symptoms  of  fracture  of  the  tibia  ? 

Usual  seat,  lower  third.  Cause,  direct  or 
indirect  violence.  Deformity,  slight,  detected 
by  passing  the  finger  along  the  subcutaneous 
edge  of  the  bone.  Mobility  and  crepitus  can 
usually  be  elicited  by  extension  and  counter- 
extension. 

What  are  the  symptoms  of  fracture  of  the 
fibula? 

Cause,  direct  or  indirect  violence.  Seat  of 
fracture,  lower  third.  Fracture  of  lower  fifth 
is  termed  PotVs fracture.  Symptoms  obscure, 
disability  and  deformity  being  slight.  Crepi- 
tus and  mobility  detected  by  placing  the  fin- 
gers over  the  seat  of  fracture  and  rotating, 
or  by  pressure  on  both  sides  of  the  suspected 
point. 

What  is  Pott's  fracture  ? 

A  fracture  of  the  fibula,  two  to  four  inches  above  its  lower  ex- 
tremity ;  the  foot  is  displaced  outward  at  the  ankle-joint.  The 
internal  lateral  ligament  is  frequently  torn.  There  may  be  a 
fracture  of  the  internal  malleolus  also. 

What  are  the  symptoms  of  Pott's  fracture  ? 

A  well-marked  depression  at  the  seat  of  fracture.  Crepitus 
and  mobility  on  local  pressure.  The  foot  is  twisted  outwards  and 
the  sole  everted  by  the  peronei  muscles  ;  the  internal  malleolus 
projects  prominently  as  if  broken,  and  the  fragments  can  be  dis- 
tinctly felt. 

Describe  fracture  of  both  tibia  and  fibula. 

Usual  cause,  indirect  force.  Seat  of  fracture,  lower  third. 
Direction  of  fracture,  oblique.  Deformity,  dependent  on  direc- 
tion of  fracture,  there  is  usually  overlapping,  and  anterior  pro- 


Pott's  fracture. 


FRACTURES. 


133 


Fig.  24. 


Fracture-box. 


jection  of  the  upper  or  lower  fragment.  Diagnosis,  all  cardinal 
signs  and  symptoms. 

How  do  you  treat  fractures  of  the  leg  ? 

All  these  fractures  may  be  treated  by  the  fracture-box,  apply- 
ing lateral  compresses  to  correct  deformity,  and  using  extension 
if  there  is  marked  shortening.  The  fracture-box  should  fix 
the  knee-joint,  should  be  strong,  and 
should  hold  the  leg  in  such  a  position 
that  the  inner  borders  of  the  inter- 
nal condyle,  the  internal  malleolus, 
and  the  ball  of  the  great  toe  lie 
nearly  in  the  same  vertical  plane, 
and  the  foot  is  kept  at  right  angles 
to  the  leg,  pressure  being  taken  off 
the  heel  by  a  pad  of  oakum  beneath 

the  tendo  Achillis.  For  very  marked  displacement,  and  diflfi- 
culty  in  retention,  flex  the  hip  and  knee,  lay  the  limb  on  its 
outer  side,  and  bind  it  to  a  double-angled  external  splint  for  a 
few  days,  then  place  it  in  the  fracture-box. 

The  fracture-box  consists  of  a  posterior  splint,  with  a  foot- 
piece  and  hinged  sides  ;  a  pillow  is  placed  in  the  box,  the  leg 
placed  on  the  pillow,  and  the  sides  brought  up  and  tied. 

External,  posterior,  anterior,  and  straight  moulded  splints 
may  also  be  used  for  these  fractures. 

PoWs  fracture  may  be  treated  with  Duxjuytreu''s  splint.  This 
consists  of  a  straight  internal  splint,  notched  at  the  lower  end, 
and  extending  from  the  head  of 
the  tibia  to  a  point  four  inches  be- 
low the  side  of  the  foot.  The  up- 
per part  of  the  splint  is  fastened 
to  the  leg,  a  thick  pad  is  applied 
to  the  lower  portion,  not  extend- 
ing below  the  internal  malleolus, 

the  foot  is  drawn  close  to  the  splint,  in  the  space  beneath  the 
pad,  by  a  figure-of-eight,  so  applied  that  there  are  no  turns 
which  make  pressure  above  the  external  malleolus.  The  knee 
is  then  bent,  and  the  leg  suspended,  or  laid  on  its  outer  side. 


Fig.  25. 


Dupuytren's  splint  applied. 


134  ESSENTIALS    OF    SURGERY. 

Describe  fractures  of  the  tarsal  bones. 

Cause,  great  violence. 

Calcaneiim  or  astragalus.  Little  displacement,  unless  the 
tuberosity  is  separated,  when  it  will  be  drawn  up  by  the  j^as- 
trocnemius  and  soleus.  Diagnosis  depends  on  crepitus,  pain, 
mobility,  and  great  swelling. 

Treatment.  Fracture-box,  or  fixed  dressing  after  subsidence  of 
swelling.  Eor  separation  and  displacement  of  the  tuberosity,  ex- 
tend the  foot  on  an  anterior  or  lateral  splint,  and  flex  the  knee. 

Describe  fractures  of  the  sternum. 

Seat,  about  the  junction  of  the  manubrium  and  gladiolus. 

Cause.  Direct  violence.  Indirect  violence  (over  flexion  or 
extension  of  the  body). 

Deformity,  readily  felt.     Irregularity  and  projection. 

Crepitus  and  mobility  by  extending  the  body,  or  causing  the 
patient  to  take  a  deep  inspiration.  Embarrassment  of  respira- 
tion, discoloration. 

This  injury  is  usually  a  diastasis,  or  separation  of  the  bone  at 
its  cartilaginous  junction.  In  this  case  the  lower  fragment  pro- 
jects anteriorly,  the  crepitus  is  smooth,  and  the  true  nature  of 
the  injury  is  suggested  by  its  location. 

Treatment.  Raise  the  chest  by  placing  a  pillow  beneath  the 
back,  force  the  patient  to  take  a  long  breath,  giving  ether  if 
necessary,  and  press  the  fragments  into  place. 

Dressing.  Broad  compress,  held  in  place  by  adhesive  straps  or 
bandages. 

Complications.  Mediastinal  abscess  and  necrosis.  Treat  the 
former  by  opening  at  the  side  of  the  sternum. 

If  the  ensiform  cartilage  is  drawn  in  upon  the  stomach,  caus- 
ing distressing  symptoms  from  pressure,  it  should  be  hooked  up 
or  resected. 

Describe  fractures  of  the  ribs. 

Cause.  Direct  or  indirect  violence,  muscular  action.  Ribs 
commonly  broken,  fifth  to  tenth. 

Ordinary  seat  of  fracture,  just  anterior  to  the  angle. 


FRACTURES.  135 

Give  the  symptoms  of  fractures  of  the  ribs. 

Crepitus  and  mobility,  elicited  by  the  pressure  of  the  thumbs, 
passing  from  the  sternum  to  the  spine.  Restriction  of  respira- 
tory movements  by  a  sharp  pain  or  stitch.  Displacement,  if 
present,  is  internal  from  direct  force,  external  from  indirect. 

Give  the  treatment  for  fractures  of  the  ribs. 

Adhesive  strips  two  and  one-half  inches  wide,  running  par- 
allel to  the  ribs,  from  the  spine  to  the  sternum,  and  each  tightly 
applied  during  expiration.  The  whole  side  of  the  chest  is  in- 
cluded. 

If  displacement  exists  it  must  he  reduced^  by  pressure,  by 
forcing  the  patient  to  inspire  deeply  under  ether,  or  by  hooking 
up  with  a  tenaculum. 

What  complications  accompany  fractured  ribs  ? 
Laceration  of  the  lung,  pleura,  or  an  intercostal  artery. 

How  do  you  treat  the  complications  ? 

Open  and  tie,  if  there  are  signs  and  symptoms  of  internal 
bleeding.  Subsequent  pleurisy  and  pneumonia  are  usually  local- 
ized and  conservative.  Emphysema  may  require  openings  in 
the  skin  (strict  asepsis). 

In  what  fractures  is  the  union  ligamentous  ? 

Xeck  of  the  femur,  olecranon,  acromion  coracoid  and  coronoid 
processes,  patella,  tuberosity  of  the  os  calcis,  spinous  processes 
of  the  vertebrae.  This  is  due,  in  part,  to  the  difficulty  in  securing 
or  maintaining  apposition. 

Describe  fractures  of  the  vertebrae. 

Cause.    Direct  or  indirect  violence. 

Seats.     Spinous  processes.     Laminae.     Body. 

Give  the  symptoms  of  fractured  vertebrae. 

Crepitus^  raoUUty,  and  deformity  may  be  detected  by  grasping 
and  manipulating  the  spinous  process,  or  pressing  upon  them,  or 
by  examination  through  the  pharynx,  in  fractures  of  the  upper 
cervical  vertebrae.  There  is  immediate  paralysis  of  the  parts 
below  the  injury,  with  loss  of  control  over  the  bladder  and 
rectum.     Temperature  of  the  paralyzed  part  is  increased. 


136  ESSENTIALS    OF    SURGERY. 

Dorso-lumhar  region.  Paraplegia,  retention  and  overflow  of 
urine,  incontinence  of  faeces. 

Boi'sal  region.  Second  to  eleventh  dorsal.  Paralysis  of  ab- 
dominal muscles,  and  muscular  coat  of  intestines.  Expiration 
markedly  embarrassed  from  involvement  of  serratus  posticus  in- 
ferior, quadratus  lumborum,  sacro-lumbalis,  longissimus  dorsi. 

Cervico-dorsal,  cervical.  If  above  the  fifth  and  sixth  cervical 
vertebrae,  paralysis  of  the  arms,  and  more  marked  embarrass- 
ment of  respiration  from  involvement  of  the  long  thoracic 
nerves  (fifth  and  sixth).  If  above  the  third  and  fourth  verte- 
brae, instant  death,  from  involvement  of  the  phrenic.  Fractures 
of  the  atlas  and  axis  need  not  be  immediately  fatal,  since  the 
canal  is  so  roomy  that  the  cord  may  not  be  encroached  upon. 

Odontoid  process  will  cause  a  prominence  in  pharynx  from  sub- 
luxation of  the  axis.    Eigid  maintenance  of  head  in  one  position. 

How  do  you  treat  fractures  of  the  vertebrae? 

If  there  is  displacement,  reduce  by  extension  and  manipulation. 
Place  the  patient  on  an  air  or  water  bed,  guarding  against  bed- 
sores by  frequent  washings  with  whiskey  and  alum,  and  careful 
padding  with  soft  pillows.  Move  the  bowels  by  encmata.  Draw 
the  water  regularly  with  a  soft,  thoroughly  aseptic  catheter.  In 
fractures  about  the  neck,  support  by  means  of  short  sand-bags. 

How  do  you  treat  fractures  of  the  extremities  complicated  by 
delirium  tremens  ? 

Carefully  pad  with  raw  cotton,  and  put  on  a  fixed  dressing,  as 
plaster  or  silica  ;  when  dry,  bind  the  limb  in  a  soft  pillow. 


LUXATIONS.  137 


LUXATIONS  OR  DISLOCATIONS. 

Define  luxation. 

A  luxation  is  the  displacement  of  the  articular  surfaces  of  a 
joint  from  their  normal  relation  to  each  other. 

Name  and  define  the  various  kinds  of  luxation. 

In  regard  to  cause — 

1.  Traumatic,  due  to  sudden  force. 

2.  Pathological  or  spontaneous,  due  either  to  alterations  of 
the  joint  from  disease  (coxalgia),  or  to  paralysis  of  the  surround- 
ing muscles. 

3.  Congenital,  due  to  congenital  malformation  of  the  joint 
(luxation  produced  by  violence  in  delivery  is  not  congenital). 

Further,  we  have  luxation  classed  as — 

Complete.  An  entire  separation  of  the  articular  surfaces  from 
each  other. 

Partial  (subluxation).  The  articular  surfaces  remain  in  con- 
tact through  a  portion  of  their  surface. 

Becent.  When  sufficient  time  has  not  elapsed  for  inflam- 
matory changes  seriously  to  impede  reduction. 

Old.     When  such  changes  have  taken  place. 

Simple,  compomid^  and  compjUcated  are  applied  to  luxations 
precisely  as  in  case  of  fracture. 

What  are  the  causes  of  luxation  ? 

(1.)  Predisposing.— 1.  The  nature  of  the  joint  (ball-and- 
socket  joint).  2.  The  position  of  the  joint.  3.  The  condition  of 
the  surrounding  soft  parts.  (Paralysis,  relaxation,  and  previous 
inflammation.)     4.  Age  and  sex  of  the  patient.     (Adult  male.) 

(2.)  Exciting. — Direct  or  indirect  violence.     Muscular  force. 

What  are  the  cardinal  symptoms  of  luxation  ? 

1.  Change  in  the  shape  of  the  joint. 

2.  Alteration  of  the  normal  anatomical  relations  of  the  bony 
prominences  about  the  joint,  the  displaced  bone  being  often  felt 
in  its  abnormal  position. 

3.  Alteration  in  the  length  of  the  limb. 


138  ESSENTIALS    OF    SURGERY. 

4.  Rigidity,  or  restricted  motion  of  the  affected  joint. 

5.  Alteration  in  the  direction  of  the  axis  of  the  bone. 

In  addition  we  have  the  symptoms  attendant  on  all  trauma- 
tisms. 
Pain  of  a  dull  sickening  character. 
Swelling  often  very  great. 
Discoloration  diffused  about  the  joint. 

How  do  you  distinguish  luxations  from  fractures  ? 

1.  In  luxation  there  is  no  harsh  crepitus. 

2.  There  is  rigidity  in  place  of  undue  mobility. 

3.  The  deformity,  when  reduced,  has  not  the  same  tendency 
immediately  to  recur. 

The  pain  is  not  so  intense,  the  swelling  and  discoloration  not 
so  rapid,  and  at  times  the  smooth  displaced  articular  surface 
may  be  felt,  while  in  fracture,  except  epiphyseal,  the  surfaces 
would  necessarily  be  rough. 

What  articular  changes  take  place  in  luxation  ? 

Rupture  of  capsular  ligament,  with  stretching  or  tearing  of 
surrounding  vessels,  tendons,  muscles,  and  nerves. 

Prompt  reduction  of  the  bone  favors  the  repair  of  the  injury. 
If  the  bone  is  not  reduced  the  articular  cavity  becomes  filled 
up,  the  prominences  rounded  off ;  a  new  socket  is  formed  about 
the  displaced  head  of  the  bone.  The  surrounding  soft  parts 
become  shortened  and  atrophied,  and  adhesions  between  the 
bone  and  the  vessels  or  nerves  often  take  place. 

What  is  the  prognosis  in  luxation  ? 

Usually  a  weakened  joint.  If  the  dislocation  is  not  reduced, 
permanent  disability,  which,  however,  is  rarely  absolute. 

How  do  you  treat  luxation  ? 

Beduce  by  either  manipulation  or  extension. 

Describe  the  methods  of  reduction. 

1.  Manipulation  consists  in  so  placing  and  moving  the  parts 
that  muscles  and  ligaments  are  relaxed,  articular  prominences  are 
disentangled  from  each  other,  and  the  head  of  the  bone  is  either 


LUXATIONS.  139 

drawn  by  the  muscles,  or  pushed  by  moderate  force  into  its  proper 
position. 

2.  Extension  consists  in  overcoming  resistance  by  force — this 
force  may  be  applied  by  the  hands,  by  wet  sheets  or  bandages 
fastened  about  the  parts,  or  by  multiplying  pulleys.  When  the 
tension  is  sufficient  to  overcome  all  resistance  the  bone  is  jjushed 
into  its  proper  position.  Retain  in  position  by  splints  and  ban- 
dages. 

How  do  you  treat  the  inflammatory  symptoms  ? 

Treat  by  evaporating  lotions  or  counter-irritants.  The  diet 
should  be  restricted  and  the  bowels  kept  opened. 

How  do  you  prevent  anchylosis  ? 

By  passive  motion,  beginning  in  seven  to  ten  days,  or  as  soon 
as  inflammatory  symptoms  subside. 

What  complications  attend  luxations  ? 

1.  Fracture.  Treat  by  setting  and  splinting  the  fracture,  then 
reducing  the  luxation. 

2.  Buxjture  of  a  large  artery^  indicated  by  a  rapidly  increasing, 
fluctuating,  pulsating  swelling.  Treat  by  rest  and  pressure,  or 
ligate  both  ends  at  the  point  of  injury,  if  it  can  be  found.  If 
this  is  impossible,  make  a  formal  ligation  of  the  artery  above. 

3.  Injury  to  nerve-trunks.  Treat  by  friction,  electricity,  mas- 
sage, incision  and  suture. 

4.  External  wound^  or  compound  luxation.  If  no  extensive 
injury  to  the  joint,  thoroughly  disinfect,  replace,  close  the 
wound,  and  fix.     If  the  bone  is  comminuted,  resect. 

How  do  you  treat  an  old  luxation  ? 

Loosen  adhesions  and  relax  contracted  muscles  and  ligaments 
by  passive  motion.  Endeavor  to  replace  the  bone  by  manipula- 
tion ;  that  failing,  use  force. 

What  accidents  may  occur  in  the  reduction  of  old  luxations  ? 

Fractures.     Set  at  once,  and  give  up  further  attempt. 
Mupture  of  important  muscles.     Put  at  rest. 
EupAure  of  pjrincipal  artery.    Ligation  of  artery  above,  or  hga- 
tion  of  both  ends  at  point  of  rupture,  or  amputation. 


140 


ESSENTIALS    OF    SURGERY. 


Buptured  vein.     Pressure. 

If  an  old  luxation  gives  little  pain  on  movement  let  it  alone, 
as  the  prognosis  is  good.  If  great  pain,  try  to  reduce,  since 
the  pain  will  prevent  the  patient  from  endeavoring  to  restore 
function. 


Fig.  26. 


Special  Luxations. 

Describe  luxations  of  the  lower  jaw. 

Direction  is  forward.     May  be  unilateral ;  more  commonly  bi- 
lateral.   May  be  partial,  the  condyles  resting  on  the  articular  emi- 
nence, or  complete  the 
condyles   slipping   into 
the  zygomatic  fossa. 

Cause.  Violence  or 
muscular  force,  applied 
when  the  mouth  is 
widely  opened.  In  this 
position  the  condyles 
ride  well  up  on  the  ar- 
ticular eminence,  and 
may  be  easily  pulled 
forward  by  the  action 
of  the  external  ptery- 
goid, and  masseter,  or 
by  direct  force.  This 
displacement  may  occur 
in  yawning,  laughing, 
Complete  luxation  of  the  lower  jaw.  etc. 

Give  the  symptoms  of  dislocation  of  the  jaw. 

Bilateral.  Mouth  widely  opened  and  rigid,  lower  jaw  thrust 
forwards,  lips  cannot  be  approximated,  hence  dribbling  of  saliva. 
A  depression  is  felt  in  the  normal  position  of  the  condyle,  the 
latter  forming  a  prominence  in  front.  Difficult  deglutition,  pain, 
and  swelling. 

Sub-luxation.  Condyles  and  lower  jaw  slightly  anterior  to 
normal  position,  jaw  rigidly  closed,  and  great  pain. 


LUXATIONS.  141 

Unilateral  luxation.  Mouth  less  widely  opened,  lower  jaw 
projected  anteriorly,  and  thrust  towards  sound  side  ;  displaced 
condyle  detected  on  the  affected  side  ;  other  symptoms  as  in 
bilateral  luxation. 

Give  the  treatment  for  dislocations  of  the  inferior  maxilla. 

Disengage  the  head  of  the  bone  from  the  zygomatic  fossa, 
when  the  internal  pterygoids  and  the  masseter  and  temporal 
muscles  will  pull  it  in  place.  This  can  be  effected  by  pressing 
downward  upon  the  molar  teeth  of  the  lower  jaw,  at  the 
same  time  pulling  up  the  chin.  The  protected  thumbs  of  the 
surgeon's  hand  are  placed  upon  the  molar  teeth,  exerting  force 
downward  and  backward,  while,  with  the  lingers,  the  chin  is 
pressed  up  ;  or  wedges  may  be  inserted  between  the  molar 
teeth  of  the  lower  and  upper  jaws  on  each  side,  and  the  chin 
forced  directly  upwards. 

Unilateral  luxation.  Force  exerted  as  before,  on  the  affected 
side  of  the  jaw. 

Sub-luxation.  Slip  a  case-knife  between  the  teeth  of  the  upper 
and  lower  jaws,  and  pry  them  open,  when  the  muscles  promptly 
reduce  the  displacement. 

Describe  luxation  of  the  ribs. 

Occurs  at  costo-cliondral  or  vertebral  articulations.     If  at  verte- 
bral extremity,  usually  associated  with  fracture. 
Sym/ptoms  as  in  fracture,  except  no  crepitus. 
Treatment  as  for  fracture. 

Describe  luxation  of  the  vertebrae. 

Nearly  always  complicated  by  fracture. 

Usual  seat.     Cervical  region. 

Symptoms.  Sudden  paralysis,  rotary  or  angular  deformity,  and 
rigidyity. 

Treatment.  Reduce  by  extension  and  counter-extension  in 
the  line  of  the  body.  Treat  subsequently  on  a  water-bed  as  for 
fracture. 

Describe  luxations  of  the  clavicle. 

More  frequent  at  acromial  than  at  sternal  extremity. 
Sternal  extremity.     Forvmrd,   by   force  applied   to  front  of 


142  ESSENTIALS    OF    SURGERY. 

shoulder.  Most  common.  BacMvard,  by  force  applied  to  back 
of  shoulder  or  applied  directly  on  sternal  extremity  of  bone. 
Upward,  very  rare,  by  force  applied  to  shoulder  from  above. 

Give  the  symptoms  of  luxations  of  the  sternal  end  of  the 
clavicle. 

Shoulder  falls  towards  median  line,  pain  on  motion.  Smooth 
articulating  surface  of  bone  felt  in  its  abnormal  position  leaving 
a  depression  in  the  seat  of  its  articulation.  If  luxation  back- 
wards or  upwards  there  may  be  dyspnoea,  dysphagia,  or  venous 
congestion  of  head,  from  pressure. 

Give  the  treatment  for  luxation  of  the  sternal  end  of  the 
clavicle. 

Forward  and  backward  luxations.  Reduce  by  knee  between 
scapulae,  pulling  shoulders  back,  and  pressing  the  bone  in  place. 

Upward  luxation.  Reduce  as  above,  or  by  placing  a  large  pad 
in  the  axilla,  pressing  the  humerus  to  the  side,  and  pushing  the 
bone  in  place. 

Dressing.  Forward  luxation.  Flex  arm  and  apply  a  Yelpeau 
or  Desault,  keeping  the  displaced  bone  in  place  by  compress 
and  adhesive  strips. 

Backward.     Posterior  figure-of-eight  and  Yelpeau  or  Desault. 

Upward.  Yelpeau  bandage,  with  compress  and  adhesive 
strips  if  persistent  deformity. 

Describe  luxations  of  the  acromial  extremity  of  the  clavicle. 

Really  luxations  of  the  scapula. 

Direction  upward,  rarely  downward  below  acromion,  or  still 
more  rarely,  below  coracoid  process. 
Cause.     Direct  blow  on  scapula. 

Give  the  symptoms  of  luxation  of  the  acromial  end  of  the 
clavicle. 

Upward  luxation.  Shoulder  falls  down  and  in.  Arm  cannot 
be  raised  over  head.  Outer  extremity  of  clavicle  very  prominent^ 
overriding  acromion  process. 

Downioard  luxation.  Same  symptoms,  except  the  acromion 
is  prominent ;  the  clavicle  leads  down  to  the  axilla  and  can  be 


LUXATIONS.  143 

felt  in  its  abnormal  position  beneath  the  acromion  or  coracoid 
process. 

Give  the  treatment  for  luxations  of  the  acromial  end  of  the 
clavicle. 

Beduce^  by  pulling  the  shoulder  backwards  and  pressing  the 
bone  in  place.  Place  a  compress  over  the  acromial  extremity 
of  the  clavicle  and  fasten  it  in  place  by  broad  straps  passing 
over  it  and  around  the  point  of  the  elbow.  Apply  a  Yelpeau 
bandage.  In  all  luxations  of  the  clavicle  reduction  easy,  reten- 
tion difficult. 

Keep  up  the  dressing  for  five  to  six  weeks,  then  carry  the  arm 
in  a  sling  for  some  time. 

Describe  dislocation  of  the  scapula. 

By  this  is  meant  the  slipping  out  of  the  inferior  angle  of  the 
bone  from  beneath  the  latissimus  dorsi. 

Cause.     Paralysis  of  the  serratus  magnus,  or  violence. 

Symptoms.  Wing-like  projection,  pain,  and  weakness  of 
shoulder. 

Treatment.  Broad  belt  which  will  keep  the  inferior  angle  of 
the  scapula  close  to  the  chest. 

Describe  the  shoulder-joint. 

Characterized  by  a  large  ball  and  small  socket,  allowing  great 
freedom  of  motion. 

Ligaments.  1.  Capsular.  Yery  lax,  weakest  at  lower  part, 
attached  to  margins  of  glenoid  cavity  and  to  anatomical  neck 
of  humerus. 

2.  Coraco-humeral.  Passing  from  root  of  coracoid  process 
downward  and  outward  to  the  front  of  the  great  tuberosity. 

3.  Glenoid.  A  triangular  ring  of  fibro-cartilage,  deepening  the 
glenoid  cavity.  The  joint  is  further  strengthened  by  the  tendon 
of  the  biceps  passing  directly  over  it,  and  invested  in  a  prolonga- 
tion of  its  synovial  membrane. 

Name  the  luxations  of  the  shoulder-joint. 

Four  in  number.  Subglenoid,  subcoracoid,  subclavicular,  and 
mbspinous. 


144  ESSENTIALS    OF    SURGERY. 

Fig.  27.  Fig.  28. 


Subclavicular. 


Subspinous. 


What  symptoms  are  common  to  all  shoulder  luxations  ? 

1.  Flattening  and  squareness  of  the  shoulder,  with  apparent 
projection  of  acromion  process. 


LUXATIONS.  145 

2.  A  depression  beneath  the  acromion  process,  where  the  head 
should  lie. 

3.  The  head  of  the  bone  can  be  felt  in  its  abnormal  position. 

4.  The  vertical  measurement  of  the  shoulders,  from  the  axilla 
around  the  acromion  process,  is  one  or  two  inches  greater  on  the 
affected  side  than  on  the  sound  side. 

5.  With  the  elbow  brought  close  to  the  body,  the  patient  can- 
not place  the  hand  of  the  injured  side  upon  the  opposite  shoulder 
(except  in  subspinous). 

6.  Alteration  in  the  axis  of  the  humerus. 

7.  Rigidity,  pain,  swelling,  discoloration,  etc. 

What  symptoms  characterize  subcoracoid  luxation  ? 

This  is  the  most  common  luxation.  1.  Head  of  bone  can  be 
felt  in  the  upper  and  anterior  part  of  the  axilla,  beneath  the 
coracoid  process. 

2.  The  humerus  stands  from  the  side  (deltoid),  and  is  some- 
what oblique  in  direction,  the  elbow  being  carried  back  (latissi- 
mus  dorsi  and  teres -major). 

3.  Pressure  on  axillary  plexus  especially  marked,  and  conse- 
quent numbness  and  tingling  in  the  arm  and  forearm. 

What  symptoms  characterize  subglenoid  luxation  ? 

Next  in  frequency.  Head  of  bone  rests  on  axillary  border  of 
scapula,  and  can  be  felt  in  the  axilla.  Elbow  carried  far  from 
the  side  (deltoid).  Lengthening  of  the  arm,  measured , from  the 
acromion  process  to  the  external  condyle  of  humerus. 

What  symptoms  characterize  subspinous  luxation? 

Elbow  carried  somewhat  forward  (pect.  major),  and  bone 
rotated  inward  (subscapularis),  the  forearm  being  thrown  across 
the  chest.  Head  of  bone  felt  on  dorsum  of  the  scapula.  Cora- 
coid process  x^rominent. 

What  symptoms  characterize  sub-clavicular  luxations  ? 

Head  of  bone  seen  or  felt  internal  to  coracoid  process,  and  be- 
low clavicle,  much  laceration  of  muscles  attached  to  tuberosities. 

Elbow  out  and  back.     All  the  characteristic  symptoms. 
10 


146 


ESSENTIALS    OF    SURGERY. 


How  do  you  treat  luxations  of  the  humerus? 

1.  Heduce  hy  raanipulation. 

Subglenoid,  suhcoracoid,  and  subclavicular.  Flex  forearm  on 
arm  (relax  long  head  of  biceps) ;  raise  the  arm  from  the  body 
(relax  deltoid  and  supra-spinatus) ;  rotate  the  humerus  outward 
(relax  infra-spinatus  and  teres  minor);  make  forcible  traction 
upon  the  humerus  with  one  hand,  sweeping  it  to  the  side  of  the 
body  and  rotating  it  inward,  carrying  the  forearm  across  the 
chest,  while  with  the  other  hand  in  the  axilla  the  head  of  the 
bone  is  pressed  into  place. 

Subspinous.  Flex  the  forearm,  grasping  the  elbow,  carry  the 
humerus  from  the  side,  rotate  inward  (subspinous),  and  with  the 
thumb  press  the  head  of  the  bone  in  place. 

2.  Beduce  by  extension. 

Heel  in  the  axilla.  Patient  supine,  surgeon  sits  down  beside 
him,  places  his  heel  (unbooted)  in  the  axilla,  and  makes  traction 

Fig.  31. 


Reduction  by  extension. 

on  the  wrist,  at  first  directly  downwards.  If  the  luxation  is  not 
reduced,  the  humerus  is  carried  across  the  chest  by  pulleys. 
Karely  employed  except  in  old  dislocations. 

After  treatment,  arm  to  side  and  axillary  pad  for  a  week, 
passive  motion  for  two  weeks,  then  allow  patient  to  use  arm. 
Old  luxations.  If  more  than  three  months  have  elapsed  and 
there  is  a  fair  amount  of  motion,  do  not  attempt  to  reduce. 


LUXATIONS.  147 


Luxations  of  Elbow. 

What  dislocations  may  occur  at  the  elbow-joint? 

Badius.     Forwards,  backwards,  outwards. 

TJlna.     Backwards. 

Both  bones.    Forwards,  backwards,  inwards,  outwards. 

Ordinary  luxation.     Both  bones  backwards. 

Describe  backward  luxation  of  both  bones. 

Cause.     Fall  on  palm  of  hand. 

May  be  comjjlete^  when  coronoid  process  of  ulna  is  lodged  in 
olecranon  fossa  of  humerus,  or  incomplete^  when  coronoid  process 
rests  upon  the  articulating  surface  of  the  humerus  (trochlear). 

Give  the  symptoms  of  backward  luxations  of  the  radius  and 
ulna. 

1.  Olecranon  projects  posteriorly,  is  out  of  line  with  condyles, 
and  the  distance  between  it  and  the  condyles  is  greatly  in- 
creased.    Head  of  radius  felt  behind  external  condyle. 

2.  A  smooth,  broad,  rounded  projection,  the  articular  ex- 
tremity of  the  humerus,  can  be  felt  in  front  of  the  elbow,  below 
the  joint  crease. 

3.  The  forearm  is  flexed,  supinated,  and  rigid. 

4.  Shortening,  from  external  condyle  to  styloid  process  of 
radius. 

Give  the  symptoms  of  forward  and  lateral  luxations  of  radius 
and  ulna  at  the  elbow. 

JBoth  hones  forward^  very  rare,  forearm  lengthened,  condyles 
of  humerus  prominent,  sigmoid  notch  can  be  felt  in  front  of  arm. 

Lateral  luxation  of  both  bones.  Great  deformity.  The  articu- 
lating extremity  of  the  radius  or  ulna  can  be  felt  in  their 
abnormal  positions,  with  marked  projection  of  the  condyle  from 
which  the  bones  are  displaced ;  joint  widened,  forearm  flexed 
and  pronated. 

Give  the  symptoms  of  luxation  of  the  ulna  at  the  elbow. 

Direction,  always  backward.  The  symptoms  are  the  same  as 
for  both  bones  backward,  except  that  the  head  of  the  radius 


H8  ESSENTIALS    OF    SURGEEY. 

can  be  felt  in  its  normal  position,  and  the  forearm  is  sliortened 
only  on  its  ulnar  as^oect. 

Give  the  symptoms  of  luxations  of  the  radius  at  the  elbow. 

Directions,  forward,  backward,  outward. 

Forward,  due  to  force  applied  in  supination. 

Backward,  due  to  forcible  pronation.  In  both,  the  head  of 
the  bone  can  be  felt  in  its  abnormal  position,  leaving  a  hollow 
below  the  capitellum  of  the  humerus.     Motion  restricted. 

Give  the  treatment  for  luxations  at  the  elbow. 

Dislocation  of  idna  or  of  both  hones. 

Forcible  flexion  of  forearm  over  the  knee  placed  in  the  bend 
of  the  elbow  ;  or  forcible  extension  of  the  forearm,  followed  by 
flexion. 

Badius.  Anterior  luxation.  Flexion  of  forearm,  direct  pres- 
sure upon  head  of  radius,  and  forced  pronations. 

Posterior  luxation.  Flexion  of  forearm,  forced  supination, 
direct  pressure. 

Dressing.  Anterior  angular  splint  one  week,  with  compress,  in 
case  of  radius  ;  passive  motion  daily.  These  luxations  become 
old  in  one  or  two  weeks.  If  attempt  to  reduce  an  old  luxation 
is  made,  first  break  up  adhesions. 

Describe  luxations  of  the  carpal  extremity  of  the  ulna. 

Cause.  Forward,  violent  supinations.  Backward,  violent 
pronations. 

Symptoms.  Projection,  with  ordinary  symptoms.  Triangular 
cartilage  always  broken. 

Treatment.  Press  bone  in  place,  apply  compress  and  bandage, 
or  adhesive  plaster,  keep  up  support  for  several  months. 

Describe  luxations  of  the  carpus. 

The  wrist-joint  is  formed  by  the  radius  and  triangular  carti- 
lage articulating  with  scaphoid,  semilunar,  and  cuneiform  bones. 

Cause  of  luxation.     Force  applied  to  hand  in  front  or  behind. 

Direction.     Backward  or  forward. 

Symptoms.  Thickness  of  wrist  greatly  increased.  Distance 
between  styloid  process  of  radius  and  base  of  metacarpal  bone 


LUXATIONS.  149 

of  thumb  lessened.  The  smooth  round  projection  of  the  carpal 
bones  felt  on  one  surface  of  the  wrist,  the  more  irregular  projec- 
tion of  the  lower  extremity  of  the  radius  felt  on  the  opposite 
surface.  Eigidity,  pain,  etc.  Hand  somewhat  flexed  in  poste- 
rior luxation,  somewhat  extended  in  anterior  luxation. 

Treatment  Posterior  disiilacement.  Flex,  press  carpus  for- 
ward, on  first  sign  of  slipping  into  place  suddenly  extend. 

Anterior  displacement.  Extend,  press  carpus  backward,  and 
on  first  sign  of  slipping  into  place  suddenly  flex.  Eeduction 
may  be  efiected  by  extension  and  counter-extension. 

Splint  and  begin  passive  motion  as  soon  as  inflammation  sub- 
sides. 

Describe  luxation  of  the  individual  carpal  bones. 

Direction.     Backwards. 

Cause.    Direct  force. 

Common  seat.     Os  magnum. 

Symptoms.  Projection  at  base  of  third  metacarpal  bone, 
with  ordinary  symptoms  of  luxation. 

Treatment.  Extend,  press  into  place,  and  apply  palmar  splint 
with  compress. 

What  luxations  may  occur  in  the  hand  ? 

Metacarpnis.     Bare. 

Direction.     Backwards. 

Symptoms.     Prominence  and  shortening. 

Treatment.     Extension,  pressure,  and  palmar  splint. 

Phalanges.  Seat.  Usually  first  phalanx  of  index  or  Uttle 
finger.     Direction.     Anterior  or  posterior. 

Symptoms.     Shortening  and  undue  prominence. 

Treatment.  Traction,  or  extreme  extension  and  forcing  bone 
into  place  by  direct  pressure. 

What  is  the  most  difficult  luxation  to  reduce  ? 

Backward  displacement  of  first  phalanx  from  the  metacarpal 
bone  of  the  thumb. 

What  is  the  cause  of  difficulty  ? 

The  head  of  the  metacarpal  bone  slips  in  between  the  two 
heads  of  the  short  flexor  of  the  thumb,  and  is  embraced  the  more 


150 


ESSENTIALS    OF    SURGERY, 


tightly,  in  proportion  to  the  amount  of  traction  exerted  on  the 
displaced  phalanx. 

What  are  the  symptoms  of  backward  luxation  of  the  first 
phalanx  of  the  thumb  ? 
Head  of  metacarpal  bone   felt  in  palmar  aspect  of  hand. 
Proximal  phalanx  extended,  terminal  flexed.     Immobility,  etc. 

Give  the  treatment. 

Forcibly  adduct  the  metacarpal  bone  into  the  palm,  extend 
the  phalanx  far  backward  till  the  thumb-nail  nearly  touches  the 
wrist,  then  suddenly  flex  on  the  metacarpal  bone,  at  the  same 
time  pressing  the  displaced  phalanx  into  position.  If  this 
method  fails,  tenotomy  of  the  flexor  brevis  pollicis. 

Name  the  ligaments  of  the  hip-joint. 

1.  Cotyloid^  a  rim  of  fibro-cartilage  deepening  the  acetabulum. 

2.  Transverse^  bridges  over  the  notch,  and  is  continuous  at 
each  end  with 


Fig.  32. 


Fig.  33. 


Y-ligament. 


Obturator  luxation. 


LUXATIONS.  151 

3.  Ligamentum  teres,  which  passes  to  a  depression  in  the  head 
of  the  femur. 

4.  Capsular,  encircHng  the  acetabuhiQi  above  and  attached  to 
anterior  intertrochanteric  Une,  to  inner  and  upper  border  of  the 
great  troclianter,  and  posteriorly  and  below  to  the  junctions  of 
the  middle  and  outer  thirds  of  the  neck  of  the  femur. 

5.  Y  -ligameTit,  a  thickened  part  of  the  capsular  hgament 
rising  from  the  anterior  inferior  iliac  spine  and  splitting  as  it 
passes  down  to  be  inserted  into  the  intertrochanteric  line. 
Lower  and  inner  part  of  joint  is  weakest. 

Name  the  dislocations  of  the  hip-joint. 

1.  Up  and  back  on  dorsum  ilii.     Iliac. 

2.  Back  in  sciatic  notch.     Ischiatic. 

3.  Forward  and  down  in  obturator  foramen.     Obturator. 

4.  Forward  and  up  on  pubis.     Suprapubic. 
Causes.     Force  apphed  when  the  limb  is  abducted. 

What  symptoms  characterize  the  backward  luxations  ? 

1.  Dorsum  ilii.  Upwards  and  backwards.  Bulging  of  hip  inova. 
displaced  trochanter  major,  which  lies  above  Nelaton''s  line  and 
nearer  the  anterior  superior  spinous  process  of  the  ilium  than 
on  the  sound  side. 

Shortening,  one  and  one-half  inches.  Pressing  the  fingers  into 
the  groin  over  the  femoral  vessels,  their  firm  base  or  support  is 
gone,  a  hollow  is  felt  instead.  Head  of  the  bone  may  be  felt 
beneath  glutei  muscles. 

Position  of  leg.  Adduction  and  inversion  due  to  Y -ligament. 
Knee  rests  against  lower  third  of  opposite  thigh.  Great  toe  rests 
on  instep  of  opposite  foot. 

Bigidity,  pain,  swelling,  etc. 

2.  Ischiatic  or  sciatic  luxation  (below  the  tendon  of  the  obtu- 
rator). 

Symptoms  the  same,  but  less  marked.  Less  shortening,  adduc- 
tion, and  inversion. 

Knee  touches,  hut  does  not  cross  opposite  knee.  Ball  of  great 
toe  rests  on  metatarsal  hone  of  opposite  side. 


152  ESSENTIALS    OF    SURGERY. 

Fig.  34.  Fig.  35. 


Dorsum  ilii. 


Isehiatie. 


Fig.  36. 


Give  the  treatment  of  backward  luxations. 

Manipulation.  Plex  leg  on  thigh  (relax  hamstring  mus- 
cles), thigh  on  abdomen,  and  still 
further  adduct  to  relax  anterior 
part  of  capsule ;  then  maintain- 
ing flexion,  circumduct  (abduct 
and  rotate)  outward  as  far  as  pos- 
ble,  bringing  the  leg  suddenly 
down  to  an  extended  position  by 
the  side  of  its  fellow.  By  this 
means  the  head  of  the  bone  is 
made  to  retrace  the  steps  by  which 
it  escaped,  and  is  wound  in  place 
by  the  Y -ligament. 
Manipulation  failing,  try 
^Extension.  Secure  counter-exten- 
sion by  strapping  the  pelvis  to  the 
floor  or  bed.  Make  extension  by 
flexing  the  thigh  on  the  pelvis  and 
pulling  directly  upward. 


Manipulation  for  reduction  of 
backward  luxation. 


LUXATIONS 


153 


Grive  the  symptoms  characterizing  forward  luxations. 

Obturator  luxation  forward  and  downward. 

1.  Psoas,  iliacus,  external  rotators,  and  Y -ligament  put  upon 
the  stretch,  hence 

Aversion  and  abduction  with  slight  flexion ^  thigh  being  carried 
somewhat  forward. 

2.  Flattening  of  hip  and,  possibly,  detection  of  bone  in  abnor- 
mal position. 

3.  Slight  lengthening  (one-half  inch). 

4.  Fixation^  swelling,  and  other  signs. 


Fig.  37. 


Fig.  38. 


Suprapntio. 


Suprapubic  luxation.     1.  Head  of  bone  readily  felt  on  pubis,  to 
outer  side  of  femoral  artery. 

2.  Shortening  (1^  inch),  with  very  marked  eversion  of  foot  and 
knee,  heel  inclining  towards  opposite  one. 

3.  Trochanter  may  be  internal  to  anterior  superior  spinous  pro- 
cess. 

4.  Depression  over  acetabulum. 


154 


ESSENTIALS    OF    SURGERY, 


Give  the  treatment  of  forward  luxations. 

Beduction.  Obturator — Flex  leg  on  thigh,  thigh  on  abdomen, 
abduct  somewhat,  then  circumduct 
inward^  carrying  thigh  over  body  and 
making  internal  rotation^  and  bring 
the  leg  down  to  the  side  of  its  fellow. 
Suprapubic  as  for  obturator,  but 
do  not  carry  the  thigh  so  far  across 
the  body. 

Give  the  after-treatment  of  all  luxa- 
tions at  the  hip-joint. 
The  knees  bandaged  together  (a 
towel  between  them)  for  ten  days, 
passive  motion  in  bed  for  two  weeks, 
,^     .     ,  ,.     ^       ^    ^.        ,    wearing  moulded  support  for  three 

Manipulation  for  reduction  of  =■  rsr 

forward  luxations.  ITLOllthS. 

Name  the  internal  ligaments  of  the  knee-joint. 

1.  Anterior  and  posterior  crucial. 

2.  The  transverse  ligament^  binding  together  the  two  semilunar 
cartilages. 

3.  The  coronary  ligament^  connecting  the  outer  borders  of  the 
semilunar  cartilages  to  the  head  of  the  tibia. 

4.  Ligamentum  mucosmn,  a  process  of  synovial  membrane,  and 
ligamenta  alaria^  its  fringed  borders. 

Describe  luxations  of  the  knee-joint. 

Cause— great  violence.  Directions — Forward,  backward,  in- 
ward, and  outward. 

Lateral  dislocations  mostly  incomplete;  more  common  than  an- 
tero-posterior. 

Give  the  symptoms  of  backward  and  forward  luxations  of  the 
knee-joint. 

1.  Shortening.  2.  Great  deformity.  The  articulating  extremi- 
ties of  the  femur  and  tibia  being  readily  felt  in  their  abnormal 
positions. 

Give  the  symptoms  of  lateral  luxations  of  the  knee-joint. 

No  shortening,  but  marked  lateral  projection  of  the  tibia,  with 


LUXATIONS.  155 

a  depression  above  ;  condyle  of  femur  prominent  on  opposite  side, 
with  a  corresponding  depression  below. 

Give  the  treatment  of  luxations  of  the  knee-joint. 

Treatment.  Flex  the  thigh,  make  extension,  and  push  bone 
in  place.     Meduction  easy. 

Apply  a  posterior  straight  splint.  Treat  the  synovitis  (cold, 
counter-irritation,  etc.),  and  begin  passive  motion  as  soon  as 
acute  inflammatory  symptoms  subside.  A  knee-cap  must  be 
worn  when  the  patient  is  allowed  to  walk. 

In  what  directions  may  the  patella  be  dislocated  ? 

1.  Outwards.  (Most  common,  from  oblique  attachment  of 
quadriceps  tendon.) 

2.  Inwards. 

3.  Quarter  rotation. 

4.  Half  rotation. 

Give  the  symptoms  of  luxation  of  the  patella. 

Outward  and  inward  luxations. 

1.  Knee  flattened  and  broadened. 

2.  Sulcus  in  normal  position  of  patella. 

3.  Patella  readily  found  in  abnormal  position. 

Give  the  treatment  for  lateral  luxations  of  the  patella. 

Ansesthetize,  flex  thigh  or  abdomen,  extend  leg  on  thigh, 
forcibly  depress  the  margin  of  the  patella  furthest  from  the 
centre  of  the  joint,  when  its  inner  edge  being  raised  and  freed, 
will  be  snapped  into  place  by  the  quadriceps. 

Give  the  symptoms  of  rotatory  luxation  of  the  patella. 

Quarter  rotation.  1.  Sharp  edge  of  patella  felt  prominently 
under  skin.     2.  Leg  fixed  in  extension. 

Half  rotation.  1.  Tendo  patella  stands  rigidly  out  and  is 
twisted.  2.  Smooth  articular  facets  of  under  portion  of  patella 
felt.     2.  Limb  rigidly  extended. 

Treatment.  Ansesthetize.  Rapid  flexion  and  extension  of 
leg  on  thigh.     If  this  fails,  employ  direct  pressure. 

Describe  luxation  of  the  semilunar  fibro-cartilage. 

Causes.     Twists  of  foot  or  leg  while  the  knee  is  flexed. 
Directions.     Inward  towards  spine  of  tibia   outward. 


156  ESSENTIALS    OF    SURGERY. 

Give  the  symptoms  of  luxation  of  the  semilunar  cartilage. 

1.  If  outward,  a  2:irojection  may  he  felt  between  tibia  and  con- 
dyle of  femur.  If  inward,  a  depression  may  he  noted  in  the  same 
position. 

2.  Sudden^  violent,  sickening  pain. 

3.  Leg  fixed  in  semi-flexion. 

4.  Rapid  effusion  into  joint. 

Give  the  treatment  for  luxations  of  the  semilunar  cartilage. 

Forcihle  flexion,  straight  posterior  splint.  Treat  accompanying 
synovitis.     A  knee  cap  must  subsequently  be  worn. 

Describe  luxations  at  the  ankle-joint. 

Directions.  Outw^ards,  inwards,  forwards,  backwards,  up- 
wards (between  tibia  and  fibula). 

May  be  compjlete  or  incomplete.  Complications.  Frequently 
fractures. 

Outward.  Always  accompanied  by  fracture  of  fibula,  fre- 
quently of  internal  malleolus  also,  or  rupture  of  internal  lateral 
ligament. 

SympAoms.  As  in  Pott's  fracture  (p.  32).  Foot  everted.  In- 
ternal malleolus  prominent. 

Inward.     Rare.     Accompanied  by  fracture  of  tibia. 

Sympjtoms.  1.  Foot  inverted.  2.  External  malleolus  promi- 
nent and  nearly  touching  ground.  3.  Depression  over  seat  of 
fracture. 

Backward.  1.  Marked  shortening  of  foot  with  toes  pointed 
downward.     2.  Lengthening  of  heel. 

Forward.  1.  Lengthening  of  foot.  2.  Heel  less  prominent. 
3.  Tibia  lies  close  to  tendo  Achillis,  which  is  relaxed. 

Upward.     Caused  by  heavy  fall  on  feet. 

Symptoms.  Joint  very  wide,  malleoli  may  be  prominent  and 
nearl}''  on  a  level  with  the  sole. 

Give  the  treatment  for  luxations  of  the  ankle-joint. 

Beduce.  Flex  leg  on  thigh,  extend  ankle-joint  to  relax  muscles 
of  calf  Extension  must  be  made  at  tbe  foot.  Counter-extension 
at  the  thigh,  while  by  manipulation  and  pressure  the  bones  are 
replaced  in  their  proper  position. 


LUXATIONS.       •  157 

After  treatment.  Control  inflammatory  symptoms  by  evapo- 
rating lotions.  Fracture-box,  or  moulded  splints  for  two  weeks, 
then  passive  motion. 

Describe  luxations  of  the  astragalus. 

Directions.     Forward,  backward,  outward,  inward. 

Forward,  most  common.    • 

Cause.     Violent  twists. 

Symptoms.  In  all  these  luxations  the  malleoli  are  nearer  the 
sole  than  they  should  be. 

Forward.  A  round  smooth  swelling  upon  the  instep,  with 
ordinary  signs  of  luxation. 

Backvjard.  1.  Hard  prominence  between  tendo  Achillis  and 
malleoli.  2.  End  of  tibia  and  fibula  prominent  anteriorly.  3. 
Foot  apparently  shortened. 

Lateral  luxations.  If  astragalus  is  thrust  outward  the  foot  is 
displaced  inward.     Internal  malleolus  very  prominent. 

Inward  luxation.  Foot  displaced  outward.  External  malleo- 
lus prominent. 

Reduce.  By  traction  and  direct  pressure,  under  ether.  Failing, 
perform  tenotomy,  dividing  all  resisting  structures.  If  skin 
sloughs  over  projecting  astragalus,  remove  the  bone. 

Failing  to  reduce,  put  in  fracture-box  and  treat  as  ankle  luxa- 
tion. 

Give  the  differential  diagnosis  between  fracture  of  the  surgical 
neck  of  the  humerus,  and  luxation  about  the  shoulder- 
joint. 

In  fracture,  crepitus.,  unnatural  mohility.  Head  of  the  hone  in 
its  normal  position^  hut  not  moving  with  shaft.  Deformity  readily 
overcome,  but  at  once  recurring  on  removal  of  reducing  force  ; 
acromion  not  especially  prominent,  and  no  undue  space  beneath 
it ;  jagged  bone  ends  may  be  felt ;  very  acute  pain.  Arm  hangs 
to  the  side. 

Luxation.  No  crepitus.  Bigidity.  A  hollow  in  the  normal 
position  of  the  head  of  the  bone.  Detection  of  head  of  bone  in 
abnormal  position,  moving  with  the  shaft.  Deformity  reduced 
with  difficulty,  after  reduction  the  bone  remains  in  its  normal 
position  ;  acromion  prominent,  with  a  space  beneath.  Shoidder 
flattened  and,  squared.     Arm  stands  from  the  side. 


158  esse'ntials  of  surgery. 

Give  the  differential  diagnosis  between  supracondyloid  fracture 
of  the  humerus,  and  backward  luxation  of  the  radius  and 
ulna. 

Fracture.  Crepitus,  mobility,  and  all  cardinal  signs  ;  olecra- 
non and  internal  and  external  condyle  in  their  normal  relation  to 
each  other  ;  no  shortening  from  external  condyle  to  styloid  pro- 
cess of  radius,  shortening  from  acromion  to  external  condyle. 

Luxation.  Immobility,  and  all  the  signs  of  luxation;  olecranon 
displaced  backward  from  its  normal  position  in  relation  to  internal 
and  external  condyles ;  shortening  from  external  condyle  to 
styloid  process  of  radius,  no  shortening  from  acromion  to  ex- 
ternal condyle. 

The  differential  diagnosis  between  any  fracture,  and  a  luxation 
in  the  same  region,  may  readily  be  given  by  bearing  in  mind  the 
cardinal  symptoms  of  each  affection. 


Sprains. 

What  is  a  sprain  ? 

The  twisting  of  a  joint,  by  which  the  soft  parts  about  it  are 
stretched  or  torn.  Muscles,  tendons,  ligaments,  nerves,  and 
bloodvessels  may  be  involved. 

What  is  a  sprain  fracture  ? 

The  tearing  away  of  scales  of  bone  to  which  ligaments  are  at- 
tached. 

What  are  the  symptoms  of  sprain  ? 

Pain  and  swelling  due  to  both  extravasation  of  blood,  and  in- 
flammatory effusion  within  and  without  the  joint.  Discoloration 
and  loss  of  function. 

Give  the  treatment  of  sprain. 

Hot  fomentations,  or  hot  bath,  lasting  for  several  hours,  fol- 
lowed by  pressure  bandage  for  two  to  four  days.  Passive  motion 
and  massage  as  soon  as  the  inflammatory  symptoms  begin  to  sub- 
side. Or,  cold  applications  and  evaporating  lotions,  followed  by 
pressure  and  massage. 


DISEASES    OF    JOINTS.  159 

Describe  sprains  of  the  back. 

Symptoms.  Pain,  stiffness,  and  disability,  appearing  some  time 
after  the  injury.  There  may  be  apparent  paresis,  together  with 
retention  of  urine  and  fseces,  due  to  the  pain  caused  by  motion. 
There  is  sometimes  hsematuria. 

Treatment.  Rest  in  the  most  comfortable  position  for  a  few 
days,  with  local  depletion  (leeches),  hot  moist  applications 
(antiseptic  poultices),  and  counter-irritants.  Then  massage  and 
use.  If  there  is  great  pain  on  motion,  a  plaster  bandage  may  be 
applied,  to  be  removed  as  soon  as  possible. 


Wounds  of  Joints, 

What  symptoms  characterize  joint  wounds  ? 

Symptoms  of  acute  inflammation,  with  distension,  due  to  ef- 
fused blood  and  synovial  fluid,  and  escape  of  the  latter  through 
the  external  wound. 

If  the  contents  of  tlfe  joint  cavity  become  infected,  the  char- 
acteristic symptoms  of  an  acute  suppurative  synovitis  and  ar- 
thritis will  appear,  together  with  the  high  fever  (103O-10o^),  and 
marked  constitutional  symptoms  of  the  affection. 

How  do  you  treat  a  wounded  joint? 

If  uncertain  as  to  whether  the  joint  is  wounded,  do  not  probe, 
but  treat  as  a  wounded  joint. 

1.  Small  incised  wounds.  Thoroughly  disinfect  the  wound  area, 
close  promptly,  using  sutures  if  necessary.  Cover  with  a  scale 
of  iodoform  and  collodion.  Carefully  splint  in  the  easiest  posi- 
tion, and  apply  cold  by  means  of  ice-bags.  If  marked  local  and 
general  inflammatory  symptoms  appear,  open  the  joint,  and 
treat  as — 

2.  Large  or  lacerated,  wounds.  Thoroughly  disinfect  the  entire 
wound  area.  Wash  out  the  synovial  cavity  with  1 :  1000  bichlo- 
ride solution,  finishing  with  1 :  5000.  Make  a  counter  opening, 
and  insert  drainage-tubes.  Suture  the  external  wound,  apply 
an  antiseptic  dressing,  splint  most  carefully,  and  elevate  the 
hmb. 


160  ESSENTIALS    OF    SURGERY. 

Synovitis. 

What  is  synovitis  ? 

An  inflammation  of  the  synovial  membrane  of  a  joint.  It  may 
be  acute  or  chronic.  There  may  be  an  effusion  consisting  of 
synovia  and  serum,  constituting  serous  synovitis.  This  effusion 
may  become  infected,  causing  purulent  synovitis. 

What  are  the  causes  of  synovitis  ? 

Exposure  to  heat  or  cold,  traumatism,  rheumatism,  gout, 
syphilis,  tuberculosis,  gonorrhoea,  and  pyaemia. 

Give  the  symptoms  of  acute  synovitis. 

Pain^  intense,  bursting.     Worse  at  night. 

Tenderness.     Slightest  touch  or  motion  unbearable. 

Swelling.  Fluctuates,  takes  the  shape  of  the  synovial  sac,  and 
appears  at  certain  portions  of  the  joint.  (At  the  sides  of  the 
quadriceps  tendon  and  beneath  the  patella,  in  the  knee-joint ; 
at  the  sides  of  the  olecranon  and  triceps  in  the  elbow-joint.) 

Muscular  atroxfhy.  Inflammatory  fever^  with  local  heat  and 
redness. 

If  suppuration  ensues,  these  symptoms,  both  local  and  con- 
stitutional, are  aggravated ;  the  patient  has  chills,  the  fever 
shortly  becomes  typhoid  in  type,  and  the  joint  becomes  red  and 
oedematous. 

How  do  you  treat  acute  synovitis  ? 

Carefully  splint  in  the  position  which  will  leave  the  most  use- 
ful limb  should  anchylosis  occur.  (Elbow  at  right  angles,  knee 
straight.)  Leeches  and  an  ice-bag  in  the  early  stages.  Aspi- 
rate if  the  synovial  sac  becomes  greatly  distended.  Light  diet, 
opium  to  relieve  pain,  regulate  the  bowels. 

If  suppuration  ensues^  incise,  irrigate,  drain,  and  dress  anti- 
septically.     Stimulants,  tonics,  and  generous  diet. 

Describe  chronic  synovitis. 

May  result  from  acute.  Synovial  membrane  may  become 
thickened  and  indurated  from  venous  congestion,  or  pass  into  a 


DISEASES    OF    JOINTS.  161 

state  of  fatty  or  '■'■  X)ulx>y''''  degeneration.     Fluid  in  the  synovial  sac 
usually  considerable  in  amount ;  clear,  or  slightly  opalescent. 

Muscular  atrophy  commonly  present.  Symptoms  of  inflamma- 
tion slight  or  wanting.  Disability  not  absolute,  joint  weak, 
but  can  be  used. 

Give  treatment  of  chronic  synovitis. 

Counter-irritation  by  blisters,  or  tr.  iodin.  Pressure  by  elastic 
bandage.  Unguent,  hydrarg.  cum  helladon.  locally.  Fixation  by 
means  of  plaster  bandages.  Injections  of  tr.  iodin.  and  distilled 
water,  equal  parts  of  each,  into  the  joint.  Treatment  of  asso- 
ciated systemic  conditions,  as  rheumatism  or  sj'philis. 

Describe  hydrarthrosis. 

Hydrarthrosis  or  hydrops  articuli  is  a  serous  effusion  into  a 
joint.  It  may  arise  from  acute  or  chronic  synovitis,  or 
spontaneously. 

Symptoms  and  treatment  as  for  chronic  synovitis.  Open  and 
drain  if  everything  else  fails. 

Arthritis. 

What  is  arthritis  ? 

Arthritis  is  an  inflammation  beginning  in  either  the  synovial 
membrane  or  the  bone,  and  affecting  all  the  structures  of  a  joint. 

What  are  the  varieties  of  arthritis  ? 

Acute.  Chronic.  Traumatic  and  infective  (pyaemia,  gonor- 
rhoea, etc.),  usually  acute.  Diathetic  (struma,  gout,  rheuma- 
tism), frequently  chronic. 

What  are  the  symptoms  of  acute  arthritis  ? 

Pain.  Throbbing,  tensile,  worse  at  night.  The  limb  is  subject 
to  spasniodic  starlings  during  sleep,  which,  from  the  pain  they 
provoke,  will  cause  the  patient  to  wake  suddenly  with  a  cry 
("  osteocopic  cry"). 

Tenderness.     Developed  to  its  most  extreme  extent. 

Swelling.     Involves  the  entire  joint  area. 

Crepitus.     May  be  felt  when  the  cartilages  are  eroded. 
11 


162  ESSENTIALS    OF    SURGERY. 

Preternatural  mobility.  Although  the  joint  is  rigidly  fixed  by 
the  muscles,  examination  under  either  will  show  softening  and 
relaxation  of  ligaments,  and  the  possibility  of  producing  motions 
not  normal  to  the  joint. 

Atrophy.     Muscles  of  the  aflfected  limb  rapidly  waste. 

Heat^  redness^  and  oedema.     Especially  when  pus  is  formed. 

Fever.  Ranges  high,  accompanied  by  rigors  when  there  is 
suppuration,  and  quickly  passes  to  the  typhoid  or  the  hectic 
type. 

What  symptoms  distinguish  arthritis^rom  synovitis  ? 

In  arthritis.  Starting  pains  at  night.  Swelling  more  diffused 
about  the  joint  and  doughy  rather  than  fluctuating.  Crepitus. 
Unnatural  mobility  and  atrophy  more  marked.  Constitutional 
symptoms  more  serious. 

Give  the  treatment  for  acute  arthritis. 

Absolute  rest  in  a  favorable  position  (splint),  with  elevation, 
and  the  application  of  cold  or  heat. 

If  suppuration  ensues,  open  freely,  drain  thoroughly,  and  treat 
antiseptically. 

In  some  cases  of  traumatic  arthritis,  or  arthritis  secondary  to 
acute  epiphysitis,  amputation  may  be  necessary,  if  the  patient 
steadily  fails  after  opening  and  draining. 

Constitutional  treatment.  Stimulants,  tonics,  and  generous 
diet. 

What  is  the  usual  cause  of  acute  arthritis  in  infants  ? 

An  acute  epiphysitis  which  suppurates,  and  quickly  involves 
the  joint.  Treatment.  Evacuate  pus  immediately,  and  splint  to 
prevent  deformity. 

What  is  white  swelling  ? 

White  swelling,  or  gelatinous  arthritis,  is  a  strumous  inflam- 
mation of  a  joint,  beginning  usually  as  a  (tubercular)  synovitis, 
and  characterized  by  slow  course,  with  ultimate  tendency  to 
total  disorganization  of  the  part. 

Swelling.     Diffiise  and  somewhat  elastic. 

Pain.     Gnawing  in  character,  not  very  acute. 

Color.     Usually  blanched. 


DISEASES    OF    JOINTS.  163 

Atrophy.     Well  marked. 

Preternatural  mobility.     Readily  detected. 

Impairment^  but  not  loss  of  fuuction. 

Give  the  treatment  for  white  swelling. 

1.  Absolute  rest,  by  means  of  fixed  dressings  kept  on  for 
months. 

2.  Tonics,  stimulants,  alteratives,  cod-liver  oil,  quinine,  iodide 
of  iron. 

3.  Fresh  air  and  good  food  in  abundance. 

Coxalgia. 

What  is  coxalgia  ? 

Coxalgia  is  a  strumous  arthritis  of  the  hip-joint,  occurring 
usually  in  persons  under  fifteen  years  of  age.  It  is  more 
common  in  boys  than  in  girls,  and  is  frequently  tubercular. 

Name  the  varieties  of  coxalgia. 

1.  Femoral.  The  disease  begins  in  the  upper  epiphysis  of 
the  femur. 

2.  Acetabular.     The  floor  of  the  acetabulum  is  first  involved. 

3.  Arthritic.     The  disease  begins  as  a  synovitis. 

Into  what  stages  may  coxalgia  be  divided  ? 

1.  Inflammation.     Flexion  snad  fixation  of  joint. 

2.  Effusion.  Flexion,  abduction,  and  fixation,  with  apparent 
lengthening  from  compensatory  curvature  of  the  spine. 

3.  Frequently  suppuration.  Flexion,  fixation,  adduction,  and 
inversion.  Apparent  shortening,  due  to  a  compensatory  curvature 
of  the  spine  in  the  opposite  direction.  Backward  luxation  of 
femur  may  take  place  in  this  stage. 

What  are  the  early  symptoms  of  hip-joint  disease  ? 

Pain,  frequently  referred  to  knee. 

Tenderness,  elicited  by  jarring  the  femur  upward,  or  pressing 
suddenly  inward  upon  the  trochanter. 

Limping,  which  may  wear  off  in  the  evening. 

Fixation,  detected  by  attempting  to  flex,  extend,  and  rotate 


164  ESSENTIALS    OF    SURGERY. 

the  femur,  when  the  muscles  resist  and  the  pelvis  is  felt  to  move 
with  the  thigh.  Place  the  patient  on  his  back,  upon  a  bed  or 
table,  and  press  the  knee  of  the  affected  side  downward  till  the 
popliteal  space  touches  the  supporting  surface,  the  lumbar  ver- 
tebra can  be  felt  arching  upwards.  Raise  the  thigh  to  a  right 
angle  with  the  pelvis,  the  vertebral  arch  disaj^pears,  and  on 
further  flexion,  the  pelvis  on  the  affected  side  is  raised  from  the 
table. 

Flexion.  The  limb  of  the  affected  side  is  slightly  flexed  and 
carried  in  advance  of  its  fellow,  the  latter  bearing  the  weight  of 
the  body. 

"What  symptoms  denote  the  further  extension  of  the  disease  ? 

Second  stage.  Pain  is  more  intense,  with  "starts"  at  night 
(showing  exposure  of  bone  by  erosion  of  cartilages).  Tenderness, 
limping,  and  fixation  are  more  marked.  Swelling  may  be  per- 
ceptible. Atrophy  is  apparent ;  nates  flattened ;  gluteo-femoral  fold 
less  distinct  than  on  the  sound  side,  circumference  of  thigh  and 
leg  lessened.  Position.  Limb  flexed,  abducted,  and  everted, 
with  pelvis  lowered  on  affected  side.     Failure  in  general  health. 

Third  stage.  Position.  Flexion,  adduction,  and  inversion, 
the  affected  thigh  crossing  the  other.  Pelvis  elevated  on  the 
diseased  side.  Shortening,  real  from  wasting,  and  apparent  from 
spinal  curvature.  Suppuration  and  abscesses  common.  Hectic 
with  rapid  emaciation. 

How  may  you  distinguish  between  the  various  forms  of  cox- 
algia  ? 

The  arthritic  form  approaches  nearer  tQ  the  type  of  an  acute 
inflammation,  with  sharp  pain  in  the  hip-joint,  swelling,  etc. 
The  femoral  variety  is  characterized  by  starting  pain  most 
marked  at  the  knee  (obturator  and  anterior  crural  nerves),  by 
shortening  and  luxation  as  the  disease  progresses,  by  abscesses 
pointing  to  outer  part  of  thigh,  below  the  trochanter. 

Acetabular.  Tendency  to  abscess  most  marked,  may  point  from 
within  the  pelvis,  over  the  nates,  or  above  Poupart's  ligament. 

What  is  the  prognosis  in  hip-joint  disease? 
Arthritic  form  is,  in  children,  favorable.     Femoral  and  ace- 


DISEASES    OF    JOINTS.  165 

tabular  forms  more  grave,  especially  the  latter.     In  .adults  the 
prognosis  is  unfavorable. 

What  are  the  complications  of  hip-joint  disease  ? 

1.  Suppuration.  2.  Amyloid  degeneration.  3.  Tubercular 
meningitis. 

How  do  you  treat  hip-joint  disease  ? 

In  light  and  beginning  cases,  a  fixation  splint  to  the  affected 
side  (Agnew's,  Thomas's,  or  a  plaster  bandage),  a  higli-soled 
shoe  (three  inches)  on  the  sound  side,  and  a  pair  of  crutches. 
For  more  serious  cases,  rest  in  led,  with  extension  apparatus,  as  in 
fractures,  applied  to  the  affected  side,  and  counter-irritation,  by 
means  of  blisters,  over  the  inflamed  joint.  On  disappearance  of 
all  symptoms  get  the  patient  up  with  high  shoe,  crutches,  and 
splint,  which  must  be  continued  for  one  year. 

Constitutional  treatment  on  general  principles.  Plenty  of  nour- 
ishing food  and  fresh  air.  Stimulants  and  tonics  as  required. 
Cod-liver  oil  and  syrup  ferri  iodidi.  Abscesses  should  be  evacuated 
promptly  by  aspiration,  or  incision  and  drainage,  under  anti- 
septic precautions. 

How  do  you  treat  anchylosis  in  a  faulty  position,  following  hip- 
joint  disease  ? 

By  subcutaneous  division  of  the  neck  of  the  femur  by  means 
of  a  strong  narrow  saw  (Adams's),  bringing  the  thigh  into 
good  position  (extension),  and  treating  as  a  fractured  femur. 

Continuous  extension  may  succeed  without  an  operation,  in  some 
eases. 

Under  what  circumstances  should  the  head  of  the  femur  he  ex- 
cised ? 

1.  When  it  is  necrosed  and  detached. 

2.  When  other  treatment  has  ftiiled  to  check  very  free  suppu- 
ration and  rapid  exhaustion  of  patient. 

3.  In  some  cases  of  displacement. 

Under  what  circumstances  is  amputation  justifiable  in  the 
treatment  of  hip-joint  disease  ? 

1.  When  there  is  extensive  disease  of  the  femur  and  free  sup- 
puration. 

2.  After  excision  which  has  not  modified  symptoms. 


166  ESSENTIALS    OF    SURGERY. 

How  do  you  distinguish  between  psoas  abscess  and  coxalgia  ? 

Psoas  abscess  can  be  felt  as  a  fluctuating  swelling,  appearing 
to  the  outer  side  of  the  bloodvessels  below  Poupart's  ligament, 
and  traceable,  through  the  abdominal  wall,  along  the  course  of 
the  psoas  muscle.  On  marked  flexion  the  pelvis  does  not  move 
with  the  femur.     Extension  gives  pain,  referred  to  the  loins. 


Sacro-Iliac  Disease. 

Describe  sacro-iliac  disease. 

Sacro-iliac  disease  is  a  strumous  arthritis  of  the  sacro-iliac 
joint,  occurring  in  early  life,  and  characterized  by — 

Pain  over  the  affected  joint,  aggravated  by  coughing,  strain- 
ing at  stool,  or  by  lateral  pressure. 

Tenderness  and  swelling  in  the  region  affected. 

Lameness  appearing  early. 

Lengthening  real,  from  downward  displacement  of  os  innomi- 
natum.     SupjmraUon. 

The  prognosis  is  bad.  Treatment  a,s  in  case  of  hip-joint  dis- 
ease. 


White  Swelling  of  the  Knee- Joint. 

Describe  white  swelling  of  the  knee-joint. 

"White  swelling  of  the  knee  is  usually  a  strumous  (tubercular) 
affection,  occurring  in  children,  and  characterized  by — 

Pain^  slight  at  first,  becomes  starting. 

Swelling,  moderate  at  first,  gradually  increasing. 

Tenderness,  particularly  marked  on  inner  aspect. 

Lameness,  not  producing  entire  disability  for  some  time. 

Displacement.  Knee  at  first  flexed,  but  as  ligaments  are  soft- 
ened and  yield,  there  is  a  hachward  displacement  and  outward 
rotation  of  the  tibia  on  the  femur. 

Crepitus,  marked.     Undue  mobility,  in  a  lateral  direction. 


DISEASES    OF    JOINTS.  167 

Abscesses  may  form,  opening  externally,  or  the  joint  may  be- 
come anchylosed. 

Treatment.  Fixation  in  good  position,  as  for  chronic  synovitis 
and  arthritis. 


Rheumatoid  Arthritis. 

Describe  rheumatoid  arthritis  (osteo-arthritis). 

Seats.     1.  Hip.     2.  Shoulder.     3.  Jaw. 

Lesions.  Absorption  of  cartilage,  ulceration  of  bone  surfaces 
with  rarefaction,  shortening  of  ligaments,  and  bony  deposits  in 
and  around  the  joint.     Occurs  after  middle  life,  usually  in  men. 

Sijmptoms.  Frequently  bilateral ;  disability,  some  deformity, 
crackling,  and  atrophy. 

Treatment.     Local  support,  quinia,  and  general  hygiene. 

Loose  Bodies  in  Joints. 

What  are  the  causes  of  loose  bodies  in  a  joint  ? 

1.  From  altered  blood-clot  (fibrinous). 

2.  From  hemorrhage  into  a  synovial  fringe,  which  subse- 
quently organizes  and  is  loosened. 

3.  From  the  gradual  detachment  of  a  synovial  fringe. 

4.  In  rheumatoid  arthritis  synovial  fringes  may  be  converted 
into  cartilage,  and  become  pediculated  or  loosened,  or  the  nodular 
masses  about  the  joint  may  project  into  the  articular  cavity. 

5.  As  the  result  of  injury,  a  portion  of  cartilage  may  be  either 
chipped  off  or  may,  by  a  process  of  necrosis,  be  shed  into  the 
joint. 

Knee-joint  usually  affected. 

Give  the  symptoms  of  loose  bodies  in  a  joint. 

Recurrence  of  attacks  characterized  by — 

Sudden^  Oijonizing  pain^  and  fixation  of  the  joint  in  slight  flexion, 
followed  by  synovitis. 

Detection  of  the  body  by  manipulation  ;  commonly  found  in  the 
pouch  over  the  external  condyle  of  the  femur. 


168  ESSENTIALS    OF    SURGERY. 

How  do  you  treat  loose  bodies  in  joints  ? 

Badical.  Secure  the  body  in  place  by  transfixing  it  with  a 
strong  needle  ;  dissect  it  out,  checking  bleeding  before  opening 
the  joint.  If  it  has  a  pedicle,  ligate.  Close  the  wound,  dress, 
and  immobilize. 

Palliative.     Knee-cap. 


Anchylosis. 

What  are  the  varieties  of  anchylosis  or  stiff  joint? 

True  anchylosis  is  dependent  on  articular  and  intra-articular 
thickening  and  adhesions.  True  anchylosis  may  be  complete^  in 
which  case  the  articular  surfaces  are  united  in  part  or  through- 
out by  bone.     Rarely  found  except  after  traumatic  arthritis. 

Or  it  may  he  incomplete,  motion  being  restricted  by  fibrous 
union  between  the  joint  surfaces,  and  thickening  of  the  capsule. 

False  anchylosis  is  dependent  on  contractions  and  adhesions  of 
the  soft  parts  around  the  joints. 

Give  the  treatment  of  anchylosis. 

Incomplete  or  fibrous  anchylosis.  Passive  motion  and  use.  Ap- 
plication of  splints,  the  angle  of  which  can  be  changed.  Continu- 
ous extension  by  means  of  weights.  Forcible  flexion  and  exten- 
sion under  anaesthetics. 

Complete  or  hony  anchylosis.  If  the  position  is  good,  let  alone, 
except  in  the  case  of  the  elbow,  which  should  be  excised.  If 
the  position  is  bad,  osteotomy  or  resection. 


DISEASES    OF    BONES.  169 


DISEASES  OF  BONES. 


Name  the  inflammatory  diseases  of  the  bones. 

Periostitis^  osteitis,  osteomyelitis,  epiphysitis. 


Periostitis. 


Describe  periostitis. 

1.  Simple  local  periostitis,  which  may  become  supjpurative  peri- 
ostitis, forming  periosteal  abscess. 

2.  Diffuse  infective  pteriostitis. 

(1)  Local  periostitis.  Cause.  Local  injury  or  extension  of  in- 
flammation from  other  parts. 

Pathology.  Thickening  of  external  fibrous  layer,  prolifera- 
tion of  inner  osteogenetic  layer,  and  inflammatory  exudate 
loosening  the  periosteum  from  the  bone.  It  may  teruiinate  in  : 
1.  Besolution.  2.  Periosteal  abscess.  3.  Periosteal  nodes  (par- 
ticularly in  chronic  periostitis). 

Symptoms.     Pain.     Intense,  bursting,  and  worse  at  night. 

Swelling  of  soft  parts  overlying. 

Tenderness.     Well  marked  on  pressure.     Fever. 

In  suppuration,  symptoms  are  increased  in  severity  ;  there  are 
oedema,  and  discoloration  of  skin. 

Treatment,  Eest  in  bed,  elevation,  cold,  opium  for  pain, 
leeches.  Should  pain  and  fever  be  unabated,  or  increase  in 
twenty-four  hours,  free  incision.  If  pus,  open.  For  osteoplastic 
periostitis  (periosteal  nodes),  oleate  of  mercury,  subcutaneous 
section,  or  ablation  by  gouging. 

(2)  Diffuse  infective  periostitis. 

Cause.     Injury  to  a  strumous  su])ject. 

Seat.     Long  bones  ;  femur,  tibia,  humerus. 

Pathology.  Rapid  septic  suppuration,  completely  separating 
periosteum  from  lx)nc. 

Symptoms.  High  fever  and  profound,  constitutional  disturbance 
rapidly  running  to  a  condition  of  septicaemia. 


170  ESSENTIALS    OF    SURGERY. 

Deep-seated  pain.  Bedness,  puffiness^  and  oedema  of  the  skin 
appear  early. 

Treatment.  Early  and  free  incisions.  Antiseptic  irrigation. 
Thorough  drainage.     Stimulants,  tonics,  and  rich  diet. 

Osteitis. 

Describe  osteitis. 

Cause.     Injury,  diathesis  (scrofula,  syphilis,  rheumatism). 

Pathology.  Inflammatory  exudation  and  cellular  hyperplasia  in 
the  Haversian  canals,  with  solution  and  removal  of  the  bone  sub- 
stance. Haversian  canals,  lacunae,  canaliculi  become  widened, 
and  may  disappear  by  coalescence.  This  constitutes  rarefying 
osteitis  or  osteoporosis.  The  bones  may  yield  to  pressure  and  be- 
come greatly  deformed,  constituting ,osieiifs  deformans.  If  the 
inflammation  is  very  acute,  rapid  proliferation  causes  strangu- 
lation of  vessels  and  the  bone  dies  in  mass  {necrosis),  or  by 
molecular  death  and  discharge  (caries).  If  inflammation  is 
somewhat  chronic,  the  absorbed  bone  is  replaced  by  a  new  de- 
posit, excessive  in  amount,  and  very  dense  (osteosclerosis  or 
osteoplastic  osteitis),  or  the  inflammation  may  result  in  a  local- 
ized collection  of  pus  [abscess  of  hone). 

Symptoms.  As  in  periostitis.  Osteocopic  (starting)  pains 
more  marked.  Tenderness  on  tapping.  (Tenderness  on  pres- 
sure greatest  in  periostitis.)     Limb  heavier  and  more  useless. 

Treatment.  As  for  periostitis.  Hot  fomentations  of  lead 
water  and  laudanum.  Subcutaneous  drilling.  Trephine.  Treat 
diathesis. 

Osteomyelitis. 

Describe  osteomyelitis. 

Definition.     Inflammation  of  the  marrow  of  the  bone. 

Cause.  Traumatism.  May  occur  primarily,  or  may  be  sec- 
ondary to  other  affections  of  the  bone. 

Varieties.     1.  Simple.     2.  Suppurative.     3.  Gangrenous. 

1.  Simple  osteomyelitis.  There  is  proliferation  affecting  the 
embryonic  cells  in  the  medulla  and  in  the  surrounding  Haversian 


DISEASES    OF    BONES.  171 

canals  and  cancellous  tissue,  the  fat  disappears,  the  bone  is 
absorbed.  Granulation  tissue  is  formed  which  may  undergo 
resolution^  may  organize  into  hone  filling  the  medullary  canal  (as 
in  case  of  fractures),  or  may  suppurate. 

2.  Suppurative  osteomyelitis.  May  be  circumscribed  forming 
bone  abscess,  or  diffuse,  leading  to  extensive  necrosis  or  pyeemia. 

3.  Gangrenous  osteo7ii.yeUtis.  Due  to  a  very  high  grade  of  in- 
flammatory action,  causing  death  by  obstruction  to  circulation. 

Complications  of  osteomyelitis.  Caries,  or  bone  ulceration.  JSTe- 
crosis,  death  of  bone  ;  this  may  be  central,  involving  the  inner 
laminse  only,  peripheral,  involving  the  outer  laminae,  or  total, 
involving  the  whole  thickness  of  the  shaft.  Sepjaration  of  epiphy- 
sis.    Inflammation  of  epiphysis.     Pyarthrosis.     Pymmia. 

Osteomyelitis  exhibits  a  tendency  to  spread  towards  the  trunk. 

Treatment.     Simple  osteomyelitis,  as  for  osteitis. 

Suppurative  osteomyelitis.  Open  with  trephine.  If  suppuration 
is  extensive  and  associated  with  pyarthrosis  (pus  in  joint), 
amputate. 

Gangrenous  osteomyelitis.     Amputate. 

Abscess  of  Bone. 

Describe  abscess  of  bone. 

Nature.     Usually  strumous. 

Cause.  Due  to  rarefying  osteitis,  or  the  breaking-up  of  case- 
ated  tubercular  masses. 

Seat.    Head  of  tibia  usually  (Brodie's  abscess). 

Symptoms.  Boring  persistent  pain,  worse  at  night.  Tender- 
ness especially  marked  on  striking  or  tapping. 

Treatment.  Apply  a  rubber  bandage  and  tourniquet  and 
search  for  pus  with  a  drill.  Trephine  ;  scrape,  and  chisel  out 
all  rough  or  carious  bone.  Pack  with  iodoform  gauze,  apply  an 
antiseptic  dressing  and  a  splint. 


172  ESSENTIALS    OF    SURGERY. 

Caries. 

Describe  caries. 

Definition.     Ulceration  or  molecalar  death  of  osseous  tissue. 

Fathology.  As  for  rarefying  osteitis.  The  surrounding  bone 
is  indurated,  except  in  struma,  when  it  is  converted  into  a 
mass  of  fungous  granulations. 

Seats.  Cancellated  extremities  of  long  bones.  Often  affects 
the  joints  secondarily. 

Symptoms.     Those  of  osteitis  with  abscess. 

On  probing,  the  softened,  roughened,  readily  bleeding  diseased 
area  is  detected.  The  discharge  contains  an  excess  of  phosphate 
of  lime. 

Treatment.  Remove  the  diseased  bone  by  the  curette,  gouge, 
or  osteotrite.  When  the  detritus  preserves  its  color  in  spite  of 
washhig,  sound  tissue  is  reached.  Excision  or  amputation  may 
be  necessary. 

Necrosis. 

Describe  necrosis. 

Definition.     Death  of  bone  in  mass. 

Direct  cause.     Osteitis  in  any  of  its  varieties. 

Bemote  cause.  Scrofula,  syphilis,  phosphorus,  exposure  to 
heat  and  cold,  etc. 

Necrosis  may  be  dry  (the  ordinary  variety),  due  to  inflam- 
matory strangulation,  or  moist,  due  to  sudden  death  from  injury. 

Necrosed  hone  is  dry,  dirty  yellow  or  brown,  hard,  and  does 
not  bleed  when  struck  with  a  probe.  When  loosened  it  is 
thrown  off  as  an  exfoliation.  The  periosteum  frequently  retains 
its  vitality,  and  throw^s  out  a  sheath  of  new  bone  surrounding 
the  dead  portion,  which,  when  it  is  entirely  separated  from  the 
living  bone  and  thus  surrounded,  forms  a  sequestrum,  and  is 
said  to  be  invaginated.  The  sheath  of  bone  investing  the  seques- 
trum is  called  the  involucrum.  The  openings  in  the  involucrum, 
through  which  the  discharge  makes  its  way  to  the  surface,  are 
called  cloaccB.  Dead  bone  is  separated  from  the  living  by  a 
jorocess  of  granulation. 


DISEASES    OF    BONES. 


17; 


Sequestrum.     Dead  bone  surrounded  by  living  bone. 

Involucrum.    A  shell  of  living  bone  surrounding  a  sequestrum. 

Cloacce.     Openings  in  an  involucrum. 

Symptoms.  Those  of  bone  in  flammation,  followed  by  free  sup- 
puration, with  discharge  of  laudable  pus  ;  this  continues  for  a 
long  time,  the  abscess  openings  contracting  down  to  sinuses. 

DicKjnosis.  Made  by  feeling  the  hard,  rough  surface  of  dead 
bone  with  a  probe. 

Treatment.  Nourishing  food,  tonics,  fresh  air,  iodide  of  iron, 
and  cod-liver  oil.    Sequestrotomy  when  the  sequestrum  is  loose. 


Tubercle. 

Describe  tubercle  of  bone. 

Three  forms.  Miliary  tubercle,  caseating  tubercle,  and  scrofulous 
osteitis  (chronic  rarefying  osteitis).  May  be  local  (encysted)  or 
diffuse  (infiltrated)  ;  more  commonly  the  latter. 

Seat.     Cancellated  ends  of  long  bones. 

Common  form.  Scrofulous  osteitis  (tubercular  nature  cannot 
always  be  proven)  ;  occurs  chiefly  on  hands,  feet  (strumous  dac- 
tylitis), ends  of  long  bones  (abscess,  or  scrofulous  arthritis),  and 
bodies  of  vertebrce  (Pott's  disease). 

Symptoms.  Those  of  osteitis,  together  with  the  signs  of  scrofu- 
lous diathesis. 

Treatment.     Air,  good  food,  general  hygiene,  etc. 

Counter-irritation,  pressure,  and  splinting.  When  suppura- 
tion takes  place,  open,  and  remove  entire  disease  area. 

Syphilitic  Bone  Disease. 

Describe  the  osseous  lesions  of  syphilis. 

Acquired.  Gummata  between  periosteum  and  bone,  forming 
periosteal  nodes.  These  nodes  chiefly  affect,  the  tibia,  ulna, 
clavicle,  and  hard  palate.  Rarely,  a  diffused  chronic  form  of  in- 
flammation causes  syphilitic  osteitis  or  sclerosis. 

Conyenital.     In  vory  young  children  cranio  tabes,  or  wasting 


174  ESSENTIALS    OF    SURGERY. 

of  bone  at  the  sites  of  decubitus,  i.  e.,  behind  the  eminences  of 
the  parietal  bones.  Alterations  in  the  epiphyseal  cartilage  making 
the  bone  hrittle  and  so/i,  Hutchinson'' s  teeth^  and  ParroVs  nodes  or 
osteophytes^  appearing  in  the  form  of  bony  projections  about  the 
anterior  fontanelle,  and  on  the  tibia  and  humerus. 


Osteomalacia. 

Describe  mollities  ossium  or  osteomalacia. 

A  disease  characterized  by  general  softening  of  the  bones,  ren- 
dering them  liable  to  be  bent  or  broken. 

Occurs  during  and  after  adult  life,  mostly  in  females. 

Pathology.  Rarefaction  and  absorption  of  bone,  advancing 
from  the  centre  outward.  Beplacement  of  medullary  tissue  by  a 
dark-red,  semi-fluid  material. 

Symptoms.  Obscure  XDain  in  the  bones  and  malaise.  Phos- 
phates in  the  urine.     Fractures,  deformity. 

"What  is  fragilitas  ossium  ? 

A  brittleness  of  bone  dependent  on  fatty  degeneration. 

Pott's  Disease. 

What  is  Pott's  disease  ? 

Pott's  disease  is  an  angular  deformity  of  the  spine  caused  by 
caries  of  the  vertebrae  or  the  intervertebral  cartilages. 

Give  the  pathology  of  Pott's  disease. 

Usually  due  to  a  tubercular  osteitis  which  affects  the  bodies 
of  several  vertebrae  simultaneously ;  these  becoming  softened, 
yield  to  the  superimposed  weight,  thus  causing  deformity.  There 
may  be  no  pus  formation,  the  inflamed  area  being  removed 
by  interstitial  absorption,  the  pus  may  become  encysted  and 
caseated,  or,  more  commonly,  may  appear  as  a  cold  abscess.  The 
cord  is  rarely  injured,  the  deformity  being  so  gradual  that  it  ac- 
commodates itself  to  its  new  course. 

Anchylosis,  which  is  a  reparative  effort,  goes  hand  in  hand 
with  the  disease,  new  bony  arches  being  thrown  out  between  the 


DISEASES    OF    BONES.  175 

vertebrae.     Pott's  disease  occurs  most  frequently  In  childhood, 
and  is  commonly  found  in  the  dorsal  and  cervical  regions. 

Give  the  symptoms  of  Pott's  disease. 

1.  General  failure  in  health. 

2.  Bigidity  of  spine.  Detected  by  getting  the  patient  to  pick 
an  object  from  the  floor,  to  rise  from  a  dorsal  recumbent  posture, 
or  to  turn  from  the  back  to  the  belly.  In  consequence  of  rigiditj'- 
and  tenderness,  the  gait  is  tottering,  shuffling,  and  uncertain. 

3.  Pain  and  tenderness,  elicited  at  times  by  jarring  the  head 
or  by  inducing  the  patient  to  jump  from  a  chair  or  step.  May  be 
found  by  direct  pressure.  There  is  a  constant  tendency  to  sup- 
port the  back  ;  the  patient  will  frequently  lie  down,  or,  if  sitting, 
will  support  the  weight  of  the  shoulders  on  the  thighs. 

4.  Bejlex  irritation.  Lumbar  disease  is  frequently  attended 
with  colicky  pain,  irritation  of  the  bladder,  and  incontinence  of 
urine.  Dorsal  disease  is  characterized  at  times  by  a  grunting 
respiration.  Cervical  disease  may  cause  torticollis,  choreic  move- 
ments of  the  neck  muscles,  or  difficulty  in  deglutition. 

5.  Deformity.  Undue  prominence  of  spinous  process  causing 
a  backward  projection. 

6.  Abscesses. 

7.  Paresis  or  paralysis. 

In  what  directions  do  the  abscesses  of  Pott's  disease  point? 

Cervical  region.  Post-pharyngeal  abscess  may  be  formed,  or 
the  pus  may  pass  outward  between  the  longus  colli  and  scaleni 
muscles,  appearing  behind  the  sterno-cleido-mastoid,  or  it  may 
pass  downward. 

Dorsal  region.  Pus  may  pass  directly  backward,  or  form 
psoas,  iliac,  or  lumbar  abscess. 

Lumbar  region.  Lumbar  abscess,  appearing  to  outer  side  of 
quadratus  lumborum.     Psoas  or  iliac  abscess. 

Give  the  treatment  of  Pott's  disease. 

Constilutiowd,  as  for  strumous  affections. 

Local.     Pest.     In  the  early  stages  rest  in  bed.     Plaster  jacket 
with  either  entire  or  partial  confinement  to  bed. 
Abscesses  must  be  opened  as  soon  as  detected.  Open  psoas  abscesses 


176  ESSENTIALS    OF    SURGERY. 

above  Poupart's  ligament  before  they  are  perceptible  in  the  groin. 
This  under  the  most  rigid  asepsis.  Dress  frequently,  washing 
out  the  abscess  cavity. 

How  is  the  plaster  jacket  applied  ? 

Bandages  two  and  one-half  or  three  inches  wide,  seven  yards 
long,  made  of  gauze,  mull,  or  crinoline.  Rub  dry  plaster  of  Paris 
thoroughly  in  the  meshes  of  each  bandage  as  it  is  rolled.  Place 
on  the  patient  a  clean  thin  summer  undershirt,  pad  all  bony 
projections  with  cotton,  put  over  the  abdomen  next  to  the  skin 
a  "dinner  pad"  (a  folded  towel),  suspend  the  patient  by  the 
head  and  shoulders,  wet  the  bandages,  and  apply  them  so  that 
the  expanded  basin  of  the  pelvis  is  caught  below  and  the  sup- 
port comes  well  up  beneath  the  axilla  of  each  side.  Remove 
the  dinner  pad  when  the  bandage  hardens. 


Rickets. 

Define  rickets. 

BicJcets  is  a  constitutional  disease  of  childhood,  characterized 
by  lesions  of  the  osseous  system,  and  a  tendency  to  amyloid  de- 
generation of  the  viscera. 

Etiology^  defective  or  unsuitable  food. 

Give  the  pathology  of  rickets. 

Increased  cell-growth,  with  deficiency  of  earthj-  matter.  En- 
largement of  epiphyseal  cartilages.  Thickening  of  periosteum. 
Softening  and  distortion  of  the  shafts  of  the  bones. 

Give  the  symptoms  of  rickets. 

Preraonitory.     Delayed  dentition.^  restlessness  at  nighty  sweating 
about  the  head,  abundant  urine  loaded  with  jyhosphates. 
Of  the  developed  disease.     Deformities.     Such  as — 

1.  Pigeon-breast,  with  beaded  ribs  from  enlargement  of  costo- 
chondral  junction. 

2.  Lateral  or  antero-posterior  curvatures  of  the  spine. 

3.  Pent  legs  or  arms  with  rounded  enlargements  at  the  ends  of 
the  long  bones. 

As  a  frequent  complication  we  have  bronchitis,  serious  on  ac- 
count of  the  yielding  nature  of  the  chest  walls. 


CURVATURE    OF    THE    SPINE.  177 

Treatment.  General  hygiene,  nourishing  diet,  cod-liver  oil, 
lactophosphate  of  lime,  iron,  sj^rup.  hypophos.  comp. 

Haemophilia. 

Describe  haemophilia. 

Haemophilia  is  a  congenital  and  habitual  hemorrhagic  dia- 
thesis, in  virtue  of  which  persistent  bleeding  may  occur,  of  it- 
self, or  from  the  slightest  wound. 

Treatment.  Compresses  saturated  in  Monsel's  solution,  strong 
pressure,  ergot,  acetate  of  lead,  and  other  haemostatics. 

Struma. 

What  is  struma? 

Struma  or  scro/wZa  is  a  defective  bodily  condition  characterized 
by  a  tendency  to  the  development  of  chronic  [tubercular)  inflam- 
mations of  the  bones,  joints,  and  lymphatic  glands. 

What  are  the  characteristics  of  scrofulous  inflammations  ? 

1.  They  develop  at  an  early  period  in  life. 

2.  They  are  chronic  in  type. 

3.  They  occur  chiefly  in  phthisical  families. 

4.  They  exhibit  a  marked  tendency  to  pass  on  to  suppuration 
and  caseation. 

5.  They  are  prone  to  appear  in  certain  regions.  Example, 
cervical  adenitis. 

Give  the  treatment  of  scrofulous  inflammation. 

Constitutional.  Generous  diet,  fresh  air  and  sunshine,  cod- 
liver  oil,  iodide  of  iron. 

Local.  Active  counter-irritation,  pressure,  operative  pro- 
cedures. 

Curvature  of  the  Spine. 

Describe  spinal  curvature. 

The  curvature  may  have  its  convexity  directed  forward,  back- 
ward, or  to  the  side. 
12 


178  ESSENTIALS    OF    SURGERY. 

The  cause  of  curvature  is  long-continued,  unequal  compression 
of  the  intervertebral  cartilages. 

Forward  curvature,  or  lordosis,  is  usually  found  in  the  lumbar 
region,  and  is  simply  an  exaggeration  of  the  normal  curve,  com- 
pensatory to  some  deformity  or  diseased  condition,  such  as 
ricket,  congenital  femoral  luxation,  coxalgia,  etc. 

Baclcward  curvature,  or  Tiypliosis,  usually  appears  as  an  exagge- 
ration of  the  normal  dorsal  curve.  It  is  the  result  of  debility, 
rickets,  or  occupation  requiring  constant  stooping. 

Treatment.  In  the  young,  friction,  massage,  deep  breathing, 
exercises  for  back  muscles,  braces  which  are  comfortable  only 
when  the  shoulders  are  held  back. 

Lateral  curvature,  or  scoliosis,  develops  most  frequently  in 
girls,  between  the  ages  of  14  and  18.  There  are  usually  two 
curves  with  their  convexities  turned  in  opposite  directions.  The 
vertebrae  are  rotated  on  their  vertical  axes,  their  spinous  pro- 
cesses pointing  towards  the  concavity  of  the  curves. 

Causes.  Inequality  in  the  length  or  strength  of  the  legs;  one- 
sided position  or  use  of  the  body  ;  contractions  following  em- 
pyema or  paralysis  of  spinal  muscles  of  one  side.  These  causes 
are  rendered  more  operative  by  debility,  or  a  strumous  or  rachitic 
diathesis. 

Symptoms.  Sense  of  fatigue  and  pain  in  back  and  shoulder 
when  sitting,  or  on  first  lying  down.  Wing-like  projection  of 
scapula  (dorsal  curvature  is  usually  toward  right),  and  undue 
prominence  of  the  iliac  crest  of  the  affected  side,  with  projection 
of  the  breast  on  the  opposite  side.  Curvature  may  be  detected 
by  marking  the  spinous  processes,  though  it  must  be  remembered 
that  the  amount  of  deformity  is  much  greater  than  is  indicated 
by  this  test. 

Treatment.  Change  in  habits  or  occupations  which  can  act  as 
exciting  causes.  Massage,  friction,  and  electricity  to  the  mus- 
cles of  the  back,  systematic  gymnastic  exercises,  suspension  fol- 
lowed by  rest  in  the  recumbent  position.  If  deformity  increases, 
apply  a  plaster-jacket. 


HERNIA.  179 

HERNIA. 

What  is  a  hernia? 

The  protrusion  of  a  viscus  through  an  abnormal  opening  in  the 
walls  of  the  cavity  in  which  it  is  contained. 

As  applied,  hernia  is  synonymous  with  rupture.,  and  indicates 
protrusion  of  the  abdominal  visceru  through  abnormal  openings 
in  the  parietes. 

What  are  the  essential  parts  of  a  hernia  ? 

1.  The  sac.     2.  The  contents. 

Describe  the  sac. 

The  sac  may  be  (1)  congenital.  Pound  only  in  umbilical  and 
inguinal  regions  ;  consisting  of  a  pouch  of  peritoneum  ready  to 
receive  the  hernia.  (2)  Acquired.  Developed  by  gradual  stretch- 
ing of  the  parietal  peritoneum.  This  is  the  form  of  sac  ordinarily 
found. 

The  formation  of  the  sac.  Pressure  of  abdominal  contents  upon 
the  parietal  peritoneum  may  cause  a  bulging  of  the  membrane 
where  it  is  poorly  supported,  as  at  the  internal  inguinal  ring  ;  the 
peritoneum  yields,  and  the  bulging  is  developed  into  a  pouch 
which  fills  the  inguinal  canal;  escaping  from  the  external  ring 
its  base  is  less  supported,  and  it  forms  a  pyriform  swelling,  con- 
sisting of— (1)  The  neck,  at  the  internal  ring.  (2)  The  body,  the 
main  part  of  the  sac.  (3)  The  fundus,  or  wide  extremity.  As 
the  peritoneum  is  dragged  downward  it  becomes  puckered  at  the 
neck. 

During  the  stage  of  (1)  Formation,  this  puckered  neck  exerts 
no  constriction  upon  the  hernial  contents. 

Stage  2.  Organization.  These  puckerings  become  adherent, 
and  the  surrounding  subserous  fat  is  indurated. 

Stage  3.  Contraction.  The  neck  of  the  sac  contracts  and  may 
become  obliterated,  or  may  cause  strangulation  if  the  gut  be 
protruding. 

The  sac,  at  first  smooth,  becomes  thickened,  contracts,  adheres, 
and  is  irreducible  ;  at  times  it  sends  off  diverticula  or  secondary 
sacs. 


180  ESSENTIALS    OF    SURGERY. 

How  are  hernias  classified  in  regard  to  the  contents  of  the  sac? 

1.  Exjiplocele.  Containing  omentum  only,  most  common  on 
left  side. 

2.  Enterocele.     Containing  intestine  only,  usually  ileum. 

3.  Entero-exnplocele.     Containing  both  omentum  and  gut. 
Further  we  may  have  cystocele  (bladder),  ccecocele  (csecum),  gas- 

trocele,  etc. 

What  are  the  causes  of  hernia  ? 

1.  Predisposing.  Sex,  males.  Heredity.  Age,  young.  Length- 
ened mesentery.  Structured  defects  (congenital).  Occupation. 
Abnormal  conditions,  such  as  a  protracted  cough,  operations  on 
the  abdomen,  and  muscular  relaxation. 

2.  Exciting.     Muscular  contraction. 

What  are  the  common  seats  of  hernia  ? 
In  the  inguinal,  femoral,  and  umbilical  regions. 

What  are  the  varieties  of  hernia  in  regard  to  their  condition  ? 

(  Cliniccd  varieties. ) 

1.  Reducible.  Most  common  form,  the  contents  can  readily 
be  returned  into  the  abdomen. 

2.  Irreducible.     Contents  cannot  be  reduced  into  abdomen. 

3.  Obstructed  or  incarcerated.  The  contained  bowel  becomes 
obstructed  by  its  contents. 

4.  Inflamed.  There  is  inflammation  or  localized  peritonitis 
of  sac  and  contents. 

5.  Strangulated.  Subject  to  a  constriction  not  only  obstruct- 
ing the  bowel,  but  seriously  interfering  with  its  circulation. 

Reducible  Hernia. 

What  are  the  symptoms  of  reducible  hernia? 

1.  Enterocele.  A  smooth,  regular,  round  tumor  in  a  hernial 
region,  often  to  be  traced  through  the  hernial  canal,  larger  on 
standing  than  on  lying  down.  Tympanitic  on  percussion,  gurgles 
when  manipulated.  Disapjpears  with  a  flop  when  pressed  inwards. 
Presents  succussion  (an  expansile  push)  on  coughing.  Local 
weakness,  dragging  pains,  and  irregular  dyspepsia. 


HERNIA.  181 

2.  EjjipIoceJe.  No  tympanites,  no  flop,  no  gurgle  ;  the  S3'mp- 
toms  the  same  but  less  marked.  Doughy  and  uneven  on  palpa- 
tion. 

Give  the  treatment  for  reducible  hernia. 

1.  Palliative.     2.  Badical. 

Palliative.  Truss,  consisting  of  pad  and  spring.  Pad  must 
be  slightly  convex,  and  large  enough  to  cover  the  external  Oi:)en- 
ing  and  the  canal  through  which  the  hernia  descends.  The 
spring  must  so  act  on  the  pad  that  the  pressure  is  just  sufBcient 
to  keep  the  hernia  up. 

To  test  a  truss,  let  the  patient  stoop,  cross  the  legs,  and  cough, 
sitting  on  the  edge  of  a  chair  with  the  body  leaning  forward 
and  legs  widely  separated. 

To  measure  for  a  truss.  (Inguinal  or  femoral.)  From  lower 
border  of  hernial  opening  to  the  anterior  superior  spine  of 
ilium  of  same  side,  from  this  point  around  the  body  one  inch 
below  crest  of  ilium  to  other  iliac  spine,  thence  to  upper  part  of 
hernial  opening. 

Directions  for  use.  Immediately  remove  truss  if  hernia  should 
come  down.  Bathe  the  skin  beneath  the  pad  with  whiskey  and 
alum  on  taking  off  the  truss,  and  before  replacing  it.  Take  off 
after  lying  down  and  replace  before  rising. 

Badical  cures.  The  various  operations  devised  for  this  pur- 
pose have  in  view  :  1.  Obliteration  of  the  necTc  of  the  sac  either  by 
ligature,  or  stitches,  or  by  plugging  it  with  the  invaginated 
fundus.  2.  The  obliteration  of  the  canal ;  and  3.  The  closure  of 
the  external  and  internal  rings. 


Irreducible  Hernia. 

What  are  the  causes  of  irreducible  hernia? 

Temporarily  irreducible,  from  slight  distension  with  fseces  or 
gas. 

Permanently  irreducible,  from  the  bulk  of  the  tumor,  constric- 
tion of  the  neck  of  the  sac,  adhesions  within  the  sac,  fatty  en- 
largement of  prolapsed  omentum. 


182  ESSENTIALS    OF    SURGERY. 

How  do  you  treat  irreducible  hernia  ? 

Tenixjorarily  irreducible^  as  for  incarcerated. 

Permanently  irreducible.  If  very  large,  apply  a  bag  truss,  if 
moderate  in  size,  fit  a  truss  with  a  concave  pad  ;  advising,  in  all 
cases  where  there  is  pain  or  discomfort,  an  operation  for  the 
radical  cure  of  the  hernia. 


Incarcerated  Hernia. 

What  are  the  symptoms  of  obstructed  or  incarcerated  hernia  ? 

Occurs  mostly  in  irreducible  hernia.,  particularly  in  such  as  con- 
tain colon.     Constipation  is  a  strong  predisposing  factor. 

1.  Tumor  is  enlarged  and  slightly  tender.  Liquid  and  gaseous 
contents  may  be  pressed  out,  and  doughy  fseces  detected. 

2.  There  is  some  pain.,  with  distension  of  the  stomachy  constipa- 
tion, nausea,  and  vomiting. 

3.  The  constitutional  symptoms  are  of  moderate  severity. 

4.  There  is  iinpidse  on  coughing. 

How  do  you  treat  incarcerated  hernia? 

Treatment.  Rest  in  bed,  cracked  ice  by  the  mouth,  complete 
relaxation  by  position.  Apply  an  ice-bag  to  the  hernia,  and 
give  opium  if  there  is  pain.  Open  the  bowels  by  purgative  ene- 
mata,  followed  by  castor  oil  as  soon  as  the  tumor  is  diminished  in 
size.     If  symptoms  of  obstruction  persist,  perform  herniotomy. 


Inflamed  Hernia. 

Describe  inflamed  hernia. 

Cause.  Injury  to  a  small  irreducible  hernia,  usually  inflicted 
by  a  badly  fitting  truss. 

Symptoms.  Chiefly  those  of  acute  local  inflaimnation.  Red- 
ness, heat,  pain,  swelling  {nodulated  if  exnplocele,  sac  contains 
fluid  if  enterocele),  impulse  on  coughing.  Fever,  vomiting,  and 
constipation  of  moderate  severity.     Wind  passed  by  bowels. 

Treatment.     Opium  if  great  pain.     Rest  in  bed  with  local 


HERNIA.    ,  183 

relaxation  by  position.  Ice-bag  to  the  inflamed  part.  Opening 
enema  (soap  and  water  Ojss).  Gentle  purgation  when  inflam- 
mation subsides. 

Strangulated  Hernia. 

What  are  the  causes  of  strangulated  hernia  ? 

1.  Sudden  descent  into  the  sac  of  an  irreducible  hernia  of  an 
additional  mass  of  omentum  or  intestine. 

2.  Sudden  descent  of  a  hernia  long  retained  by  a  truss. 

3.  Parietal  constriction  about  the  opening  of  a  hernia  suddenly 
produced  by  violent  effort. 

Where  is  the  seat  of  constriction  ? 

1.  At  the  neck  of  the  sac.  At  times  in  the  body  of  the  sac, 
from  hour-glass  constriction. 

2.  Entirely  within  the  sac.  Due  to  bands  of  lymph,  or  a  rent 
in  the  omentum. 

3.  Erdirely  without  the  sac.  In  small  hernia  suddenly  pro- 
duced by  violent  effort. 

What  changes  take  place  in  strangulated  hernia? 

Bowel  is  grooved  by  constriction,  becomes  oedematous,  ecchy- 
mosed,  red  deepening  into  purple,  loses  its  lustre^  becomes  harsh, 
sticlcy,  non-elastic^  and  dirty  hlack. 

Sign  of  local  death — loss  of  lustre  and,  elasticity. 

Ma}^  rupture  into  the  sac,  or  at  the  line  of  constriction.  In- 
flammatory adhesions  mostly  prevent  feecal  extravasation  into 
the  peritoneal  cavity. 

Sac,  attacked  by  inflammation,  effuses  serum. 

What  are  the  symptoms  of  strangulated  hernia  ? 

1.  Tumor  becomes  more  tense,  somewhat  duller  on  percussion, 
tender  at  the  neck  of  the  sac,  and  gives  no  succussion  on  coughing. 

2.  Abdominal  pain,  with  sense  of  constriction  about  umbilicus. 

3.  Vomiting,  frequent  and  persistent;  first,  contents  of  stomach, 
then  bile,  finally  fi&eces. 

4.  Obstinate  constipation. 


184  ESSENTIALS    OF    SURGERY. 

5.  Bapid  loss  of  strength;  small^  rapid^  compressible  pulse;  dry, 
brown  tongue.  Yery  little  urine  passed,  it  may  contain  albumen 
and  indican,  and  be  deficient  in  clilorides. 

Gangrene  is  denoted  by  cessation  of  ptain  and  vomiting,  and  rapid 
development  of  symptoms  of  collapse. 

What  is  Littre's "hernia? 
A  hernia  involving  only  a  portion  of  the  circumference  of  the 
bowel.     Though  the  pouch   is  strangulated, 
there  is  not  absolute  internal  obstruction. 

What  are  the  symptoms  of  Littre's  hernia  ? 

As  for  strangulated  hernia,  but  less  marked; 
vomiting  not  stercoraceous,  constipation  not 
absolute.     Tumor  is  small,  and  gangrene  rap- 
idly develops  ;  hence  the  treatment  is  early 
Littre's  hernia.        herniotomy. 

What  are  the  principal  points  in  the  diagnosis  of  strangulated 
hernia  ? 

1.  Stercoraceous  and  persistent  vomiting. 

2.  Absolute  constipation. 

3.  Great  constitutional  depression. 

4.  Absence  of  succussion,  or  impulse  on  coughing. 

How  do  you  treat  strangulated  hernia  ? 

Kest.     Relaxation  of  parts  by  position.     Taxis.     Herniotomy. 

How  do  you  employ  taxis? 

Anaesthetize,  and  fully  relax  by  position  (flexion  and  adduction 
of  thigh  for  femoral  or  inguinal  hernia).  The  head  and  shoulders 
should  be  low,  the  pelvis  elevated.  Define  the  neck  of  the  sac 
with  the  thumb  and  forefinger  of  the  left  hand,  then  with  the 
fingers  of  the  right  hand  draw  the  sac  down  a  little,  and  by  a 
kneading,  rolling,  compressing  movement  press  the  gut  in  a  di- 
rection corresponding  to  its  line  of  the  descent. 

In  oblique  inguinal  hernia  the  pressure  must  be  outwards,  up- 
wards, backwards. 

In  femoral  hernia  first  slightly  downwards  till  falciform  pro- 
cess is  cleared,  then  directly  backwards  towards  pubic  spine. 

Taxis  failing  in  five  to  eight  minutes,  perform  herniotomy. 


HERNIA. 


185 


Under  what  circumstances  must  taxis  be  avoided  ? 

1.  Yery  acute  cases,  as  in  hernia  of  sudden  development,  from 
violent  muscular  action. 

2.  Where  symptoms  of  strangulation  have  existed  for  several 
days. 

3.  Where  the  strangulated  gut  was  previously  irreducible. 

4.  Where  the  gut  is  gangrenous. 

What  accidents  may  occur  in  the  employment  of  taxis? 

1.  Reduction  en  masse  or  en  hloc.  The  hernia,  together  with  its 
sac,  is  pushed  directly  inward,  the  strangulation  being  in  no  way 
relieved.    Denoted  by  slow,  dif- 


Fig.  41. 


Fig.  42. 


Reduction  en 
bloc. 


Reduction  en 
bissac. 


ficult,  forcible  reduction  not  ac- 
companied by  gurgle  or  flop, 
and  by  persistence  of  symptoms. 

2.  Reduction  en  bissac.  The 
bowel  is  pressed  into  a  congeni- 
tal diverticulum  or  poucli,  run- 
ning from  the  body  of  the  sac 
below  or  beneath  the  abdominal 
muscles.  Symptoms  the  same 
as  reduction  en  bloc. 

3.  Reduction  through  a  rup- 
ture in  the  neck  of  the  sac,  the 

hernia  escaping  into  the  subserous  cellular  tissue. 

These  three  forms  are  usually  classed  as  reduction  en  hloc. 
Treatment.  Cut  down,  secure  the  sac,  open  it,  and  divide  the 
constriction  at  the  neck. 

4.  Bupture  of  Intestine.     Rapid  collapse,  no  gurgle. 

Under  what  circumstances  may  symptoms  persist  after  complete 
reduction? 

1.  Paralysis  of  bowel. 

2.  Internal  strangulation  (causes  within  sac). 

3.  Acute  peritonitis. 

What  treatment  should  follow  reduction  by  taxis  ? 

Compress  and  bandage  locally.   Absolute  rest,  milk  diet;  opium 


186  ESSENTIALS    OF    SURGERY. 

to  quiet  pain.     If  no  inflammatory  symptoms,  open  bowels  by 
castor  oil  or  iDurgative  enemata  the  fifth  day. 

What  treatment  should  follow  continuance  of  symptoms  after 
reduction  ? 

Exploratory  laparotomy^  and  careful  search  for  causes  of  ob- 
struction. 

Describe  herniotomy. 

Empty  bladder  and  rectum.  The  antiseptic  method  must  be 
carried  out  to  its  minutest  details.  Shave  the  seat  of  operation, 
pinch  up  a  fold  of  skin  and  transfix,  cutting  outward  and  making 
an  incision  about  three  inches  long.  Divide  the  successive  layers 
of  tissue  on  a  grooved  director  till  the  sac  is  reached.  The  sac  is 
tense^  rounded^  bluish,  with  arborescent  vessels.  Pinch  up  a  small 
portion  with  forceps,  and  notch  ;  a  straw-colored  or  blood-stained 
serum  escapes.  Open  freely  with  scissors,  pass  the  finger  up  to 
the  seat  of  constriction,  slip  the  nail  under  the  resisting  band, 
pass  a  probe-pointed  hernia  knife  along  the  finger,  turn  the  edge 
forward,  and  divide  the  stricture.  If  the  gut  is  in  good  condi- 
tion, return  ;  then  restore  the  mesentery,  and  sew  across  the  neck 
of  the  sac,  removing  its  body,  or  do  a  formal  radical  operation. 
Insert  a  drainage-tube,  close  the  external  wound,  and  apply 
antiseptic  dressing,  compress,  and  bandage. 

1^0  food  for  twenty-four  hours,  then  milk  diet.  Enema  in 
two  days. 

How  should  the  intestine  be  managed  ? 

Beturn  if  it  be  smooth,  glistening,  and  elastic,  even  though  there 
be  great  discoloration  and  ecchymosis.  Draw  down  a  little  more 
of  the  gut  and  inspject  the  line  of  constriction  before  returning. 
This  is  a  common  seat  of  perforation. 

All  manipmlations  must  be  practised  with  great  gentleness. 

A  dull  black,  sodden,  sticky  bowel  is  beyond  hope  of  recovery 
and  must  not  be  returned. 

How  do  you  treat  gangrenous  bowel? 

Lay  open  the  sac,  carefully  relieve  the  stricture,  incise  the 
gut  if  it  is  greatly  distended,  dress  with   charcoal   poultice. 


HERNIA.  187 

This  leaves  either  a  fecal  fistula  (a  small  aperture  discharging 
faeces),  or  an  artificial  anus  (a  double-barrelled  opening). 

If  only  a  limited  portion  of  the  bowel  is  gangrenous,  excise, 
and  unite  the  healthy  tissue  with  Czerny''s  suture^  the  first  row 
including  only  the  edge  of  the  serous  membrane,  the  second 
(Lembert's)  starting  one-half  inch  from  the  edge  of  the  wound, 
and  including  a  quarter  of  an  inch  of  all  the  coats  of  the  bowels 
except  the  mucous  membrane. 

How  do  you  treat  a  faecal  fistula  or  an  artificial  anus  ? 

The  fcecal  fistula  frequently  closes  spontaneously  ;  if  not,  a 
plastic  operation  may  be  performed,  or  it  may  be  treated  as  an 
artificial  anus. 

In  artificial  amis  the  spur  or  partition  formed  by  the  anterior 
projection  of  the  posterior  wall  of  the  bowel  may  be  ulcerated 
through  by  means  of  Dupuytren's  euterotome,  after  which  the 
external  opening  may  be  closed  by  a  plastic  operation;  or  the 
intestine  may  be  detached  from  the  abdominal  wall,  drawn  out, 
freshened,  and  united  by  Czerny's  suture.  Prepare  by  twenty- 
four  hours'  light  diet,  and  thorough  washing  out  of  the  bowels. 

How  should  the  omentum  be  managed? 

If  acutely  strangulated,  clamp,  excise,  secure  the  bleeding 
points,  and  return  the  stump  to  the  abdominal  cavity.  If  ad- 
herent, excise.     Omentum  must  not  be  left  in  the  sac. 

How  do  you  treat  adhesions  ? 

Break  down  recent  adhesions.  Apply  two  ligatures,  and  cut 
between  old  vascular  adhesions. 

How  do  you  treat  the  sac  ? 

Dissect  it  out,  suture  across  the  neck,  and  excise  below  the 
suture  line. 

What  is  the  after  treatment  ? 

No  food  for  thirty-six  hours.  Morphia  hypodermically  for 
pain.  Stimulants,  if  necessary,  by  the  rectum.  Open  bowels  by 
an  enema  the  seventh  day.  Remove  the  drainage-tube  in  forty- 
eight  hours,  the  sutures  on  the  fourth  day.  Keep  up  firm  pres- 
sure by  means  of  ]>andages.  In  one  month  apply  a  truss  and 
get  the  patient  out  of  bed. 


188 


ESSENTIALS    OF    SURGERY, 


Special  Hernias. 

What  are  the  varieties  of  hernia  in  regard  to  position  ? 

Diaphragmatic,         Inguinal,  Femoral, 

Epigastric,  Obturator,        Lumbar,        Perineal, 


Yentral, 


Umbilical, 


Ischiatic, 


Pudendal. 


Fig.  43. 


Inguinal  Hernia. 

What  is  the  most  common  variety  of  hernia? 

Inguinal  hernia. 

Name  the  varieties  of  inguinal  hernia  ? 
1.  Acquired. 

Complete.  When  the  hernia  has  passed  through  the  external 
ring. 

Incomplete.     When  the  hernia  is  still  in  the  inguinal  canal, 
called  also  Bubonocele. 

Oblique.  Commonest  variety. 
The  hernia  passes-  to  the  outer  side 
of  the  epigastric  artery,  and  if  com- 
plete, through  the  two  rings  and  the 
canal. 

Direct.  The  hernia  passes  to  the 
inner  side  of  the  epigastric  artery 
and  through  the  external  abdominal 
ring  only. 

Further,     a    complete    inguinal 
hernia    reaching    the    scrotum    is 
called    scrotal,   or  the    labium,   in 
woman,  is  termed  labial. 
Barer  forms,  depending  upon  congenital  defects,  are — 
1.   Congenital  hernia.     In  this  the  peritoneal  process  (vaginal 
process),  accompanying  the  testis  in   its   descent,  remains  an 
open  pouch  and  receives  the  gut. 


Inguinal  hernia. 


HERNIA 


189 


Fi^.  45. 


Fig.  46. 


Infantile 
hernia. 

Fig.  47. 


2.  Hernia  into  the  funicular  Fig.  44. 
'portion  of  the  vaginal  process  [in- 
fantile hernia).  This  implies  the 
same  condition  as  before,  ex- 
cept that  the  proper  tunic  of 
the  testis  has  become  closed, 
the  funicular  (cord)  portion  of 
the  process  alone  remaining 
patulous. 

3.  Encysted  hernia.  The  ven- 
tricular orifice  of  the  peritoneal 
pouch  is  closed,  the  funicular 
and  testicular  parts  remaining 
open.  This  hernia  is  of  gradual 
formation.  It  invaginates  the 
existing  pouch   and  carries   an 

additional  layer  of  peritoneum  Encysted  hernia. 

with  it,  making  three  layers  of 

serous  membrane  to  be  cut  through. 

Describe  the  inguinal  canal. 

The  inguinal  canal  is  an  oblique  passage  through  the  anterior 
abdominal  wall,  lying  parallel  to  Poupart's  ligament  and  above 
it.  It  begins  at  the  internal  ring,  ends  at  the  external  ring,  and 
is  one  and  one-half  inches  long.  It  transmits  the  spermatic 
cord  in  man,  the  rounded  ligament  in  woman.     It  is  bounded — 

In  front.,  by  the  external  oblique,  internal  oblique  (outer 
third),  cremaster  muscles. 

Behind,  by  the  conjoined  tendon  (inner  third),  transversalis 
fascia,  triangular  ligament,  sub-peritoneal  tissue,  deep  epigastric 
artery,  and  peritoneum. 

Above.,  by  the  arch  made  by  the  internal  oblique  and  trans- 
versalis. 

Belov:)^  by  Poupart's  ligament  and  the  transversalis  fascia. 

Describe  the  internal  abdominal  ring. 

The  internal  abdominal  ring  is  an  oval  opening  situated  in 
the  transversalis  fascia,  one-half  inch  above  the  middle  of  Pou- 


190  ESSENTIALS    OF    SURGERY. 

part's  ligament.  Above  and  external  to  it  lie  the  arched  fibres 
of  the  transversalis,  below  internally  the  deep  epigastric  artery. 
From  its  circumference  a  thin  funnel-shaped  membrane,  the  in- 
fundibuliform  fascia,  is  continued  around  the  cord 

Describe  the  external  abdominal  ring. 

The  external  abdominal  ring  is  a  triangular  aperture  in  the 
fascia  of  the  external  oblique  muscle,  bounded  below  by  the 
crest  of  the  pubis,  above  by  the  intercolumnar  fibres.  Internally 
and  above  by  the  internal  column  inserted  upon  the  front  of  the 
pubic  symphysis.  Externally  and  below  by  the  external  column, 
inserted  upon  the  pubic  spine. 

Describe  Poupart's  lig^ament. 

Poupart's  ligament  is  that  portion  of  the  fascia  of  the  external 
oblique  muscle  extending  from  the  anterior  superior  spinous  pro- 
cess of  the  ilium  to  the  pubic  spine.  In  the  lower  portion  it 
forms  the  external  column  of  the  external  ring ;  a  backward  re- 
flection from  the  pubic  spine  to  the  pectineal  line  forms  Gimher- 
naVs  ligament.  A  band  of  tendinous  fibres  continued  from  its 
attachment  to  the  pectineal  line  up  and  in  towards  the  linea  alba 
forms  the  triangular  ligamerd. 

What  is  the  cremasteric  fascia  ? 

It  consists  of  the  muscular  fibres  carried  down  from  the  in- 
ternal oblique  by  the  testicle  in  its  descent ;  they  form  a  series 
of  loops  covering  the  cord.   , 

What  are  the  coverings  of  an  oblique  inguinal  hernia? 

Skin,  two  layers  of  superficial  fascia,  intercolumnar  fascia 
(from  columns  of  external  ring),  cremasteric  fascia  (from  canal), 
infundibuliform  fascia  (from  internal    ring),  peritoneum  (true 

sac). 

Name  the  coverings  of  a  direct  inguinal  hernia. 

Skin,  superficial  fascia,  intercolumnar  fascia,  conjoined  ten- 
don, transversalis  fascia,  and  peritoneum. 

If  the  hernia  passes  to  the  outer  side  of  the  conjoined  tendon, 
this  structure  is  replaced  as  a  covering  by  the  cremasteric  fascia. 


HERNIA. 


191 


What  effect  has  a  long-standing  inguinal  hernia  upon  the 
length  of  the  canal? 

The  internal  ring  is  dragged  down  till  it  lies  almost  directly 
behind  the  external  ring. 

What  is  the  relation  of  the  cord  to  inguinal  hernial 

Below  and  behind. 

In  what  direction  should  the  incision  be  made  in  relieving  the 
stricture  of  an  inguinal  hernia  ? 

Upward  and  outward,  parallel  to  Poupart-s  ligament. 

Describe  congenital  hernia. 

The  testis,  in  its  descent  into  the  scrotmn,  is  accompanied  by  a 
peritoneal  pouch.  The  pouch  becomes  occluded  at  two  points, 
the  internal  ring,  and  the  top  of  the  epididymis.  The  portion 
between  these  two  points  occupies  the  whole  of  the  inguinal 
canal ;  it  shortly  shrinks,  and  is  transformed  to  a  fibrous  cord. 

If  the  peritoneal  process  remains  patent  throughout,  we  have 
the  condition  which  gives  rise  to  congenital  hernia. 

If  it  is  occluded  at  the  lower  end,  hernia  of  the  funicular  pro- 
cess [infantile  hernia). 

If  it  is  occluded  at  the  upper  end  only,  and  the  occluding  sep- 
tum yields,  we  have  infantile  hernia. 

How  do  you  diagnose  these  forms  of  hernia? 

Congenital  and  funicular  hernia  (infantile)  usually  occur  in  early 
life,  are  of  sudden  development,  become  complete  at  once,  do  not 
drag  down  the  internal  ring.  They  are  very  prone  to  become 
strangulated,  and  are  difficidt  to  reduce. 

The  congenital  hernia  intimately  surrounds  the  testicle  ;  all 
other  forms  of  hernia  lie  above  it. 

The  encysted  hernia  cannot  be  diagnosed  before  cutting ;  then 
it  will  be  found  to  have  a  double  sac. 

Congenital  hernia  may  be  associated  with  undescended  tes- 
ticle, "in  this  case  it  will  protrude  outward  along  the  fold  of 
the  groin. 

Pro<mosis  of  congenital  hernia  is  good. 


192  ESSENTIALS    OF    SURGERY. 

With  what  affections  may  inguinal  hernia  be  confounded? 

Vm'icocele^  hydrocele  of  the  cord,  congenital  hydrocele,  and  en- 
larged i7iguinal  glands. 

How  do  you  diagnose  hernia  from  varicocele  ? 

Varicocele  feels  soft,  doughy,  and  like  a  hunch  of  worms  to  the 
fingers.  Disappears  on  lying  down,  to  appear  again  on  stand- 
ing, but  first  enlarges  at  the  bottom  of  the  scrotum.  If  it  is  made 
to  disappear,  and  the  finger  is  placed  over  the  external  ring,  it 
will  appear  more  quickly  than  before.  No  gurgling,  no  tympa- 
nites, slight  succussion.  An  omental  hernia  may  feel  doughy, 
but  not  like  a  bunch  of  earth-worms,  the  enlargement  comes 
from  above,  and  if  reduced,  the  finger  placed  over  the  external 
ring  will  prevent  it  from  reappearing. 

How  do  you  diagnose  inguinal  hernia  from  other  affections  of 
the  same  region  ? 

Hydrocele  of  the  cord  is  translucent,  enlarges  like  varicocele 
from  the  bottom,  and  fluctuates.  It  has  neither  gurgling  nor 
tympanites. 

Undescended  testicle.  Absence  of  gland  on  affected  side,  hard 
tumor  in  inguinal  canal,  sickening  pain  on  pressure. 

Enlarged  inguinal  glands.  Direction  of  tumor  oblique  to  long 
axis  of  canal.  It  is  hard,  very  painful,  and  the  skin  is  reddened. 
Tumor  freely  movable  at  first.  Hernia  lies  in  the  long  axis  of 
the  inguinal  canal,  is  soft,  is  not  painful,  the  skin  is  normal,  the 
tumor  lies  very  deep,  and  is  immovable. 

Femoral  Hernia. 

Describe  the  femoral  canal. 

The  femoral  or  crural  canal  is  a  narrow  interval  below  Pou- 
part's  ligament,  between  the  femoral  vein  and  the  crural  sheath 
(sheath  of  the  vessels). 

It  is  one-quarter  to  one-half  inch  long,  extending  from  the 
femoral  ring  to  the  upper  border  of  the  saphenous  opening.  The 
septum  crurale  closes  the  canal  at  the  femoral  ring,  the  cribri- 
form  fascia  at  the  saphenous  opening. 


HERNIA 


19^ 


Femoral  hernia. 


Describe  the  femoral  ring. 

The  femoral  ring  lies  between  Poupart's  ligament  above, 
the  pubis  and  pectineus  muscle  be- 
low, with  Ginibernat's  ligament  to 
the  inner  side,  the  femoral  vein  to 
the  outer  side.  It  is  oval  in  shape, 
about  one-half  inch  in  diameter,  and 
is  closed  by  the  septum  crurale  and 
a  lymphatic  gland. 

Describe  the  saphenous  opening. 

The  saphenous  opening,  formed 
by  a  reflection  of  the  fascia  lata 
beneath  the  femoral  vein,  is  an  oval- 
shaped  aperture,  one  and  one-half 
inches  in  length,  one  inch  in  breadth, 
situated  beneath  the  inner  portion  of  Poupart's  ligament. 

Its  upper  and  outer  margin,  sharply  defined  and  semilunar  in 
shape,  passes  in  front  of  the  vessels  and  is  inserted  into  the 
pubic  spine  and  pectineal  line.  It  is  called  the  superior  cornu 
of  the  falciform  process.  Its  lower  and  inner  margin  forms  the 
inferior  cornu  of  the  falciform  process. 

The  inner  margin  is  formed  by  the  fascia  passing  to  the  pec- 
tineal line,  curving  upwards  and  behind  the  femoral  vein,  cover- 
ing in  the  pectineus  muscle.  This  portion  of  the  ring  is  not 
sharply  defined. 

"What  are  the  boundaries  of  the  femoral  canal  ? 

Anterior.  Poupart's  ligament,  transversalis  fascia,  falciform 
process  of  fascia  lata. 

Posterior.     Iliac  fascia,  pubic  portion  of  fascia  lata. 

Internal.  The  junction  of  the  transversalis  and  iliac  fascia, 
forming  the  inner  wall  of  the  crural  sheath,  Gimbernat's  liga- 
ment. 

External.     The  septum  covering  the  femoral  vein. 

What  are  the  coverings  of  femoral  hernia  ? 

Skin,  superficial  fascia,  cribriform  fascia,  crural  sheath,  septum 
crurale,  [)eritoneum. 
13 


194  ESSENTIALS    OF    SURGERY. 

Where  is  the  gut  commonly  strangulated  in  a  femoral  hernia? 

Gimbernat's  ligament.  Superior  cornu  of  falciform  process, 
or  Hay's  ligament.     (Aguew.) 

What  important  structures  lie  near  the  femoral  ring  ? 

1.  Spermatic  cord,  just  above  tlie  superior  margin. 

2.  Epigastric  artery,  passes  above  to  the  outer  side. 

3.  Obturator  artery,  may  curve  across  the  upper  and  inner 
border. 

4.  Femoral  vein  to  the  outer  side. 

How  do  you  distinguish  femoral  from  inguinal  hernia  ? 

Femoral  hernia,  traced  upvv^ard  towards  its  neck,  is  found  to 
pass  to  the  outer  side  of  the  pubic  spine.  Inguinal  hernia 
passes  to  the  inner  side. 

In  what  direction  should  you  cut  in  relieving  the  constriction 
of  a  strangulated  femoral  hernia  ? 
Upward  and  inward,  using  a  blunt-pointed  knife  with  a  dull 
edge. 

How  do  you  distinguish  femoral  hernia  from  a  psoas  abscess? 

They  both  give  succussion,  and  disappear  on  pressure  or  recum- 
bency. Psoas  abscess  comes  down  to  the  outer  side  of  the  vessels, 
gives  the  signs  of  the  diseased  condition  by  which  it  is  caused, 
and  fluctuates.  It  can  be  traced  above  PouparVs  ligament. 
Hernia  appears  to  the  inner  side  of  the  femoral  vessels  and  has 
the  characteristic  signs.  It  cannot  be  traced  above  Poupart's 
ligament. 

Umbilical  Hernia. 

What  are  the  varieties  of  umbilical  hernia  ? 

1.  Congenital^  depends  upon  imperfect  closure  of  the  ventral 
plates,  the  sac  extends  into  the  cord  and  has  been  tied  by  the 
accoucheur. 

2.  Acquired^  depends  upon  yielding  of  the  abdominal  cicatrix. 
This  is  the  comnionest  variety  of  umbilical  hernia,  both  in  infants 
and  adults. 


HERNIA.  195 

What  are  the  coverings  of  an  umbilical  hernia  ? 

Skin,  superficial  fascia,  linea  alba,  sac. 

How  do  you  treat  umbilical  hernia  ? 

In  infants,  draw  the  recti  muscles  together,  strap  tightly,  and 
apply  a  binder  or  bandage.  In  adults  apply  a  protecting  con- 
cave truss. 

Where  should  the  incision  for  relief  of  strangulated  umbilical 
hernia  be  made  ? 

In  the  linea  alba,  beginning  a  couple  of  inches  above  the  upper 
margin  of  the  hernia.     The  parietal  tissues  are  often  very  thin. 


196  ESSENTIALS    OF    SURGERY. 


INTESTINAL  OBSTRUCTION. 

Give  the  causes  of  acute  intestinal  obstruction. 

1.  Congenital  malformation,  imperforate  anus,  etc. 

2.  Impaction  of  foreign  bodies  and  gall-stones. 

3.  Invagination  or  intussusception. 

4.  Volvulus  or  twisting,  commonly  dependent  on  mesenteric 
elongated. 

5.  Internal  strangulation,  or  constriction  of  the  bowel  by 
bands  or  diverticula  having  no  structural  connection  with  the 
circumference  of  the  constricted  gut. 

Symptoms  of  acute  Intestinal  obstruction  may  also  appear  in 
erderitis^  peritonitis,  and  perityphlitis;  or  in  chronic  obstruction. 

Give  the  symptoms  of  acute  intestinal  obstruction. 

Pain^  often  intense  and  localized.  Vorniting^  gastric,  bilious, 
intestinal,  and  finally  faecal.  Constipation,  absolute.  Abdomen 
swollen,  tender,  tympanitic.  Peristalsis  increased,  causing  borbo- 
rygmus  and  gurgling.  Gh^eatrntal  depression.  Small,  rapid  jmlse. 
Temperature  may  be  normal  or  subnormal  till  just  before  death, 
which  commonly  occurs  in  from  seven  to  ten  days. 

How  may  the  seat  of  acute  intestinal  obstruction  be  inferred  ? 

The  probability  of  the  small  intestine  being  involved  is  in 
direct  proportion  to  the  acuteness  of  the  pain  and  the  rapidity 
of  the  course.  Early  and  severe  vomiting,  scanty  urine,  and 
early  distension  all  point  to  small  intestine. 

What  are  the  causes  of  chronic  obstruction  ? 

Fsecal  accumulation,  stricture  of  the  bowel,  glueing  of  the  in- 
testines together  from  chronic  peritonitis  or  cancer,  abdominal 
tumors. 

Give  the  symptoms  of  chronic  obstruction. 

Constipation;  abnormal  distension  very  slowly  developed  ;  vom- 
iting comes  on  slowly  or  may  be  absent ;  pain  rarely  acute  ;  con- 
stitutional depression  not  marked. 


INTESTINAL    OBSTRUCTION.  197 

What  are  the  special  characteristics  of  intussusception  ? 

This  is  the  common  form  of  acute  obstruction  in  infancy  and 
childhood.  Usual  seat,  ilio-colic  valve.  It  is  characterized  l>y 
tenesmus  and  passage  of  mucus  and  blood. 

Sausage-shaped  tumor  usually  to  the  left  side  of  the  abdomen. 

On  examination  per  rectum  the  invaginated  gut  may  be 
found. 

Give  the  treatment  for  intussusception. 

Inflation  per  rectum  with  air  or  water ;  inversion  ;  gentle 
kneading  of  the  bowels. 

Laparotomy^  and  reduction  by  kneading  and  drawing  down  the 
sheath  or  outer  tube.  If  reduction  is  not  possible,  make  an  arti- 
ficial anus,  or  cut  off  the  intussuscepted  part,  and  suture  together 
the  two  ends  of  the  bowel. 

What  are  the  special  characteristics  of  internal  strangulation? 

Occurs  during  adolescence  or  early  adult  life. 

Patient  has  been  previously  healthy,  symptoms  following  a 
hlow  or  a  straining  efibrt. 

Symptoms  tery  acute.  Severe  pain  referred  to  umbilicus  with 
intense  prostration  or  syncope.    There  is  no  peristalsis,  no  tumor. 

What  are  the  special  characteristics  of  volvulus  ? 

Occurs  in  advanced  life. 

Seats.  Sigmoid  flexure  of  colon,  and  in  the  neighborhood  of 
the  ilio-ctecal  valve. 

Symptoms  are  characterized  by  extreme  rapidity  and  severity. 

Give  the  treatment  of  acute  intestinal  obstruction. 

31al:e  most  carefid  search  in  all  hernial  regions  for  strangidation. 
Keep  the  patient  in  the  recumbent  position.  Give  liquid  nour- 
ishment and  in  minimum  quantity.  Morphia  gr.  ^  every  three 
to  six  liours,  as  required  to  relieve  pain.  Hot  fomentations  to 
the  belly.  Cocaine,  hydrocyanic  acid,  etc.,  for  vomiting.  If, 
after  a  reasonable  time-(one  to  three  days,  according  to  the  se- 
verity of  the  symptoms),  there  is  no  change  for  the  better, 
laparotomy,  witli  further  measures  adapted  to  the  relief  of  the 
obstruction. 


198  ESSENTIALS    OF    SURGE  KY. 

Give  the  treatment  of  chronic  intestinal  obstruction. 

Enemata.  If  from  impaction  of  faeces,  break  up  mechanically 
and  remove.  If  from  malignant  trouble,  or  stricture,  excision, 
with  circular  enterorraphy  or  artificial  anus. 

What  is  laparotomy  ? 

Opening  the  abdominal  cavity. 

Incision.  Linea  alba,  midway  between  pubes  and  umbilicus, 
large  enough  to  admit  the  fingers.  Stop  all  bleeding  before  open- 
ing peritoneum.  Explore  first  all  the  hernial  rings,  then  the 
ccECum.  If  it  be  distended^  obstruction  must  be  in  large  intestine, 
and  can  be  found  by  searching  along  the  colon.  If  caecum  empty, 
search  for  an  empty  loop  of  small  intestine,  which  can  be  fol- 
lowed up  till  the  seat  of  trouble  is  reached. 

If  intestine  sloughing,  enterectomy  (excision),  and  artificial  anus 
01  circular  enterorraphy  (suture). 


Diseases  of  the  Anus  and  Rectum. 

Describe  the  varieties  of  congenital  malformation  of  the  anus 
and  rectum. 

1.  Partial  or  complete  occlusion  of  the  anus.  There  is  a  mem- 
brane of  varying  thickness,  bulging  when  the  child  cries  or 
strains,  and  thin  enough  for  the  meconium  to  be  detected. 

2.  Imperforate  anus.  Tlie  rectum  terminates  in  a  blind  pouch, 
from  half  an  inch  to  an  inch  from  the  surface  ;  the  normal  posi- 
tion of  the  anus  is  occupied  by  dense  tissue. 

3.  Occlusion  of  the  rectum.  A  membranous  septum  is  found 
from  half  an  inch  to  an  inch  above  the  anal  orifice. 

4.  In ij^^erf orate  rectum.  Kectum  wanting.  The  colon  termi- 
nates in  a  blind  pouch  in  the  iliac  fossa. 

5.  Malformation  with  abnormal  opening  in  other  parts. 

How  do  you  treat  congenital  malformation  of  the  anus  and 
rectum? 

Place  the  child  in  lithotomy  position. 

Incision  in  the  middle  fine,  over  the  natural  position  for  the 
anus.     Work  backward  toward  the  coccyx.     The  bowel  being 


DISEASES    OF    THE    ANUS    AND    RECTUM.       199 

found,  open,  and,  if  possible,  suture  to  the  external  wound.  Pass 
a  bougie  daily  to  prevent  contraction.  If,  after  dissecting  to  the 
depth  of  1^  inches,  no  sign  of  bowel  is  perceived,  do  Littre's 
operation  (left  inguinal  colotomy),  making  an  artificial  anus. 

What  are  hemorrhoids  ? 

Swellings  about  the  margins  of  the  anus  due  to  a  varicose 
condition  of  the  bloodvessels.  Hemorrhoids  may  be  external, 
affecting  the  muco-cutaneous  folds  external  to  the  sphincter,  or 
internal.,  affecting  the  mucous  membrane  within  the  sphincter. 

What  are  the  causes  of  hemorrhoids  ? 

Anything  tending  to  increase  the  supply  of  blood  to  the  rectum, 
or  to  impede  its  venous  return.  Instance,  liver  troubles,  constipa- 
tion, straining,  occupations  requiring  much  standing,  sedentary 
life.  They  begin  as  dilations  of  the  hemorrhoidal  veins,  and  are 
followed  by  infiltration  of  surrounding  tissues. 

Describe  external  piles. 

May  be  made  up  of  dilated  and  thrombosed  veins,  thrornhotic; 
may  be  due  to  swollen  muco-cutaneous  folds,  oedernatous ;  or  may 
consist  of  permanently  hypertrophied  flaps  or  tags  of  skin, 
cutaneous.  These  occasion  little  trouble  till,  from  cold,  consti- 
pation, imprudent  diet,  or  some  other  cause,  they  become  in- 
flamed, when  they  give  rise  to  intolerable  pain  and  itching,  and 
exhibit  all  the  local  signs  of  an  acute  inflammation  ;  this  con- 
stitutes an  "attack  of  piles." 

Give  the  treatment  of  external  piles. 

Keep  the  bowels  open  by  equal  parts  confection  of  senna  and 
confection  of  black  pepper,  or  a  glass  of  Friedrichshall  on  rising 
in  the  morning  ;  scrupulous  cleanliness  of  the  parts.  Cocaine 
suppository  (gr.  |)  for  acute  attacks. 

t'hrornhotlc.  Apply  a  ten  grain  to  the  ounce  calomel  ointment 
at  night  and  in  the  morning,  after  washing.  If  the  parts  become 
very  painful,  incise  and  turn  out  the  clot. 

Describe  internal  piles. 

May  be  open  or  hleediiu/,  blind  or  not  bleeding. 

1,  Capillary  hemorrhoids.  Small,  granular,  bright  red  tumors, 
situated  high  in  the  bowel ;  really  arterial  ncjem. 


200  ESSENTIALS    OF    SURGERY. 

2.  Arterial  liemorrhoids.  Hard,  vascular,  glistening,  slippery  ; 
may  attain  considerable  dimensions.  On  scratching,  briglit  red 
blood  in  jets.  Large  artery  can  be  felt  entering  the  upper  part 
of  each  pile. 

3.  Venous  hemorrhoids.     Large,  livid,  prone  to  prolapse. 

What  are  the  symptoms  of  internal  hemorrhoids  ? 

Bleeding  at  stools.  The  blood  is  bright  red  and  coats  the  fceces. 
Protrusion.  An  irregularly  nodulated  congested  mass  protrudes 
after  defecation.  It  may  become  strangulated  by  the  sphincter. 
Constipation.  Discomfort  and  heaviness  about  the  rectum.  Pain 
and  fever ^  if  the  piles  are  inflamed  or  strangulated. 

Give  the  treatment  for  internal  piles. 

1.  Palliative.  Equal  parts  of  senna  and  black  pepper  confec- 
tion, a  teaspoonful  on  rising.  Coat  the  diseased  area  with  ferri 
subsulph.  3ss,  cosmoline  Jj.  Inflamed  piles.  Laudanum  and 
starch- water  injections.  Hot  fomentations.  Cocaine  supposi- 
tories (gr.  \).  For  strangulated  piles,  anaesthetize,  and  return 
within  the  sphincter. 

2.  Operative.  Clear  the  lower  bowel  by  laxatives  and  injection. 
Lithotomy^  or  the  lateral  position.  (1)  Injection  of  carbolic  acid. 
Clamp  the  pile  and  inject  TTlv  of  a  20  per  cent,  glycerine  and 
water  carbolic  solution  into  the  ceiitre  of  the  pile.  (2)  Ligature. 
Paralyze  the  sphincter,  draw  down  each  pile,  divide  the  skin 
about  it,  and  encircle  its  base  by  a  ligature  ;  or  transfix  with  a 
needle  carrying  a  double  thread,  and  tie  each  half  separately. 
Insert  an  opium  suppository  and  apply  a  T  bandage  with  a 
compress  of  iodoform  gauze.     Open  the  bowel  on  the  fifth  day. 

3.  Clamp  and  cautery. 

4.  Crushing. 

5.  Excision. 

Give  the  treatment  for  secondary  hemorrhage  after  pile  opera* 
tions. 

Cold  injections.  Insert  rubber-bag  and  inflate  with  cold 
water.  Pass  in  a  full-sized  drainage-tube  and  pack  the  rectum 
about  it  with  styptic  cotton  or  gauze  (containing  subsulphate). 


DISEASES    OF    THE    ANUS    AND     KECTUM.      201 

Name  the  forms  of  prolapse  of  the  rectum. 

Partial,  involving  only  mucous  membrane. 
Com'plete,  involving  all  the  tissues  of  the  gut  (really  an  invagi- 
nation). 

Name  some  of  the  causes  of  prolapse. 

Belaxation.     Undue  straining.     Irritation,  such  as  that  caused 
by  ascarides,  polypus,  stone  in  bladder,  phimosis. 
Usually  occurs  in  children  or  aged  people. 

Give  the  symptoms  of  prolapse. 

A  protrusion  of  a  soft,  non-nodulated,  non-pediculated,  smooth 
mass  about  the  entire  circumference  of  the  anus,  continuous 
with  the  mucous  coating  of  the  sphincter  in  the  partial  form. 

Give  the  treatment  of  prolapse. 

Reduce.  Patient  in  knee-breast  posture  ;  bowel  covered  with 
oiled  lint  and  pushed  up.  If  strangulated,  divide  the  sphincter. 
After  reduction  strap  the  nates  together  (plaster),  keep  bowels 
soluble,  and  let  them  be  moved  while  the  patient  is  in  the 
recumbent  or  standing  posture.  The  cold  douche,  or  astringent 
injections  are  often  serviceable. 

Operative.  1.  Take  up  longitudinal  folds  of  mucous  membrane 
in  Smith's  clamp,  cut  off  with  scissors,  and  cauterize  pedicle 
[clamio  and  cautery).  2.  Ligate  portions  of  the  mucous  mem- 
brane. 3.  Apply  nitric  acid  to  entire  prolapsed  surface,  cover 
with  carbolized  oiled  lint,  and  restore. 

What  is  a  fistula  in  ano  ? 

An  abnormal  communication  between  the  rectum  and  the 

surface. 

Usual  cause.     Abscess. 

Name  the  varieties  of  fistula  in  ano. 

Complete,  having  a  gut  and  a  surface  opening.  The  gut  open- 
ing is  usually  just  above  the  internal  sphincter. 

Incomplete  or  Uind,  having  but  one  opening. 

a.  External,  opens  on  surface  only. 

h.  Internal,  opens  in  Ijovvel  only. 


202  ESSENTIALS    OF    SURGERY. 

What  are  the  symptoms  of  fistula  in  ano  ? 

1.  Discharge.  Thin  pus,  causing  excoriations,  and  coating  the 
fseces  in  the  internal  or  blind  variety, 

2.  Local  signs  of  inflammation^  which  are  subject  to  frequent 
exacerbations. 

3.  Opening^  sometimes  very  small.  On  using  a  probe  its  end 
will  be  felt  by  the  finger  in  the  rectum,  either  passing  into  the 
bowel,  or,  if  there  be  no  internal  opening,  lying  beneath  the  mu- 
cous membrane. 

Give  the  treatment  for  fistula. 

Operation.  Pass  a  grooved  director  along  the  fistulous  tract 
till  its  point  is  felt  on  the  finger  introduced  into  the  bowel,  hook 
it  forward  bringing  it  out  through  the  anus,  divide  the  structures 
thus  raised  upon  the  director  and  all  sinuses  or  pockets  communi- 
cating with  the  fistula.  Do  not  divide  the  sphincter  in  more 
than  one  place.  In  women  do  not  divide  the  sphincter,  as  it 
decussates  with  the  vaginal  fibres.  Wipe  out  the  wound  with 
caustic  potash,  pack  with  lint  saturated  in  carbolized  oil,  and 
allow  the  wound  to  heal  from  the  bottom. 

What  is  anal  fissure  ? 

Anal  fissure  is  a  lineal  idcer  or  crach  usually  ^/j^st  within  the 
anus.     Caused  by  constipation,  and  large  hard  passages. 

Give  the  symptoms  of  anal  fissure. 

1.  Smarting  pain  coming  on  after  defecation,  often  intense  and 
radiating  from  rectum.  Smarting  changed  to  an  aching  sensation, 
which  may  last  for  several  hours. 

2.  Faeces  streaked  with  hlood. 

How  do  you  diagnose  anal  fissure  ? 

Examination  is  pam/?^^;  the  sphincter  and  levator  ani  arc 
spasmodically  contracted.  Two  oedematous  folds  of  mucous 
membrane  are  found,  which  being  separated  reveal  the  ulcer. 

Give  the  treatment  of  anal  fissure. 

1.  Keep  the  bowels  loose  (cascara  sagrada  gr.  iij.  at  night,  or 
Hunyadi  Janos  on  rising),  wash  with  soap  and  warm  water  after 
each  passage,  and  apply  ferri  subsulph.  (gr.  x  to  5J  cosmoline). 


DISEASES    OF    THE    ANUS    AND    RECTUM.       203 

2.  Anffistbetize  the  patient.  Insert  the  thumbs  into  the  anus, 
separate  them  till  the  ischial  tuberosities  are  felt. 

3.  Local  ansesthesia  by  cocaine  (gr.  xx  to  5j).  Draw  a  bis- 
toury longitudinally  through  the  base  of  the  ulcer  from  above 
downwards. 

What  other  forms  of  ulceration  occur  about  the  anus  and 
rectum  ? 
Syphilitic,  tubercular,  senile  (varicose). 

Give  the  symptoms  of  ulcer  of  the  rectum. 

Tendency  to  morning  diarrhoea.  There  is  an  urgent  desire  to 
open  the  bowels  immediately  on  rising. 

Pain,  moderate.     Tenesmus,  relieved  by  evacuation. 

Discharge.  Mucus  or  muco-pus,  at  times  containing  also 
disintegrated  blood. 

Ulcerated  surface  is  seen  and/e?i  on  examination. 

Give  the  treatment  of  ulceration  of  the  anus  and  rectum. 

Treat  constitutional  condition.  Highly  nutritious  diet,  bowels 
soluble.  Night  and  morning,  cleansing  injections  of  warm  bor- 
acic  acid  solution  (ad  lib.),  or  boroglyceride  ;  at  night  starch 
water  and  laudanum  gttxx  by  injection.  In  severer  cases 
nitric  acid  directly  to  ulcer,  applied  through  speculum. 

Name  the  varieties  of  stricture  of  the  rectum. 

1.  Fibrous.     2.  Malignant. 

What  is  the  cause  of  simple  (fibrous  stricture)  ? 
Inflammation  or  ulceration. 

What  are  the  symptoms  of  fibrous  stricture  ? 

1.  Co7istipation,  slowly  increasing. 

2.  Motions  like  pipe-stems,  or  broken  up  into  scyhala. 

3.  A  sense  of  fullness  after  fxissages,  as  though  there  were  more 
to  come. 

4.  Diarrhf^a,  alternating  with  consti^jation,  or  predominating. 
Constant  desire  to  go  to  the  closet,  passage  of  very  little  solid, 
with  yeasty  liquid. 

5.  Wind  which  cannot  be  passed  except  in  the  closet,  as  it  is 
accompanied  by  a  liquid  discharge. 


20J:  ESSENTIALS    OF    SURGERY.  * 

6.  Excoriation  and  inflammation  of  anus  from  discharge. 
Frequently  fistula. 

By  examination  the  stricture  can  usually  be  felt. 

Give  the  treatment  for  fibrous  stricture  of  the  rectum. 

Gradual  dilatation  by  means  of  bougies.  Partial  or  complete 
division  of  the  stricture.  Inguinal  colotomy.  Excision  of  stric- 
ture. 

Give  symptoms  and  treatment  of  malignant  stricture  of  the 
rectum. 

Usually  epithelioma ;  about  half  inch  above  anus.  In  addi- 
tion to  the  signs  of  stricture,  there  is  intense  jictin  radiating  from 
the  seat  of  trouble,  there  is  frequently  free  bleeding,  and  the 
discharge  is  profuse,  offensive,  watery,  or  often  bloody,  and 
becomes  finally  like  coffee-grounds.  Cancerous  cachexia  always 
develops.  On  examination,  the  abnormal  growth  is  detected  ; 
indurated,  nodulated,  and,  if  the  disease  is  advanced,  with 
fungoid  out-croppings  over  its  surface,  which  break  down  under 
the  examining  finger,  coating  it  with  a  blood-stained  offensive 
muco-pus. 

Treatment.  Excision  if  the  disease  is  strictly  local,  inguinal 
colotomy  if  there  is  systemic  involvement. 

Give  the  symptoms  of  impacted  faeces. 

Constipation,  distension,  pain,  and  very  frequently  a  spuriom 
diarrhoea,  i.  e.,  a  mucous  semi-fasculent  discharge,  due  to  the 
irritation  of  the  impacted  mass. 

Diagnosis  by  rectal  examination. 

Treatment.  Break  up  the  lower  part  of  the  mass  with  the 
finger  or  the  handle  of  a  wooden  spoon,  and  wash  away  by 
means  of  copious  injections. 

Describe  polyp  of  the  rectum. 

2'wo  varieties.  1.  Fibrous.  Smooth  surface,  may  reach  large 
size.  2.  Adenoid.  Identical  in  structure  with  the  mucous  mem- 
brane; looks  very  much  like  a  raspberry.  Both  usually  pedun- 
culated; occur  in  children. 

Symptoms.     Bleeding  after  stools,  and  prolapse. 

Treatment.     Lisate  and  remove. 


DISEASES    OF    THE    ANUS    AND    RECTL'M.       205 

Describe  villous  tumors  of  the  rectum. 

Practically  a  mass  of  non-pediculated  adenoid  polyps. 
Sijmptfn-iis.     Hemorrhages,  feeling  of  fulness  in  rectum,  and 
thin,  mucoid,  glutinous  discharge. 

On  examination  a  lohidated,  soft,  velvety,  mouibJe  mass  is  found. 
Treatment.     Complete  removal. 

Describe  pruritus  ani. 

Obstinate  itching  about  the  anus  ;  frequently  depending  on 
local  irritation  (as  pediculi,  threadworms,  piles),  or  on  gouty 
diathesis ;  it  may  be  without  obvious  cause. 

Give  treatment  of  pruritus  ani. 

Kemoval  of  cause,  strict  cleanliness,  regularity  in  the  motions 
from  the  bowels,  exercise,  Turkish  baths.  Suppositories  of 
cocaine  (gr.  I)  or  iodoform  (gr.  v),  morphine,  carbolic  acid, 
mercurial  ointment.  Alum  and  zinc  sulphate,  equal  parts  of 
each,  fuse,  powder,  dissolve  in  5j  aq. ;  use  as  injection.  A  rec- 
tal plug  may  be  worn  at  night. 


206  ESSENTIALS    OF    SURGERY. 


VENEREAL  DISEASES. 

What  is  syphilis? 

Syphilis  is  a  constitutional  disease,  due  to  inoculation  with 
specific  virus. 

What  is  the  primary  lesion  of  syphilis  ? 
The  chancre. 

What  is  the  period  of  primary  incuhation  ? 

The  time  which  intervenes  between  inoculation  and  the  ap- 
pearance of  chancre.  Rarely  earlier  than  two  weeks  or  later 
than  five ;  average,  three  weeks. 

What  is  the  period  of  secondary  incuhation  ? 

The  time  between  the  appearance  of  chancre  and  the  develop- 
ment of  secondary  symptoms.  Rarely  before  the  first  or  after  the 
third  month  succeeding  the  chancre. 

When  do  the  tertiary  s3miptoms  appear  ? 

At  a  period  varying  from  a  few  months  to  many  years  after 
the  secondaries. 

Describe  chancre  or  primary  sore. 

Found  commonly  about  the  corona  glandis,  may  appear  any- 
where. Contracted  directly^  by  contact  with  chancre  or  second- 
aries (mucous  patches),  indirectly  from  articles  used  by  syphilitics. 

Appears  as  an  indurated  papule,  which  develops  into  an 
abrasion,  tubercle,  or  ulcer. 

What  are  the  characteristics  of  the  primary  sore  ? 

1.  Indurated  base  and  thin,  scanty  secretions. 

2.  Inflammation  slight  around  the  sore. 

3.  Usually  single,  not  autoinocidahle. 

4.  Buboes  are  polyganglionic  and  painless  ;  rarely  suppurate. 

5.  Appears  after  an  incuhation  period  and  is  followed  by  sec- 
ondaries. 

The  Hunterian  chancre  is  characterized  by  greater  depth,  freer 
discharge,  and  more  marked  induration. 


VENEREAL    DISEASES.  207 

The  mixed  chancre  exhibits  tlie  peculiarities  of  botli  syphilitic 
and  chancroidal  inflammation. 

Give  the  treatment  of  chancre. 

Wash  several  times  daily  with  black  wash,  and  dust  with 
calomel,  subiodide  of  bismuth,  iodol,  or  iodoform.  Bo  not  begin 
mercury  till  the  secondaries  ap^jear. 

Describe  the  secondary  lesions  of  syphilis. 

1.  General  enlargement  of  the  lymphatic  glands. 

2.  Eruptions  of  the  skin  and  mucous  membranes  ;  at  times,  in- 
flammation of  the  iris  or  periosteum,  and  falling  of  the  hair. 

Pathology.     Congestion,  infiltration,  ulceration. 

The  development  of  secondaries  is  preceded  by  general  malaise, 
fever,  and  ansemia,  lasting  a  few  days  and  disappearing  on  the 
appearance  of  roseola  and  sore  throat. 

The  skin  eruption  may  simulate  tlie  various  forms  of  skin  dis- 
ease. It  may  be  erythematous  (s.  roseola),  papular  (s.  lichen), 
vesicular  (s.  herpes,  eczema,  and  varicella),  bullous  {s.  pemphigus), 
or  pustular  (s.  ecthyma,  acne,  or  variola). 

Mucous  membrane  lesions. 

Pathology,  as  in  the  skin,  first  congestion  (syphilitic  sore 
throat),  then  infiltration  with  maceration  of  the  epithelium 
(mucous  patches),  finally  ulcers. 

What  are  the  characteristics  of  syphilitic  skin  eruptions  ? 

1.  Absence  of  itching. 

2.  Symmetrical  arrangement  (on  the  two  sides  of  the  body). 

3.  Reddish-brown  or  coppery  in  color  (raw  ham). 

4.  Polymorphous  (many  kinds  of  eruption  at  the  same  time). 

5.  Therapeutic  test  (use  of  mercury). 

Describe  the  mucous  patch. 

Synonyms.     Condyloma.     Mucous  tubercle. 

Pathology.  A  congested,  infiltrated  macule,  the  surface  of 
which  is,  from  its  peculiar  position  (about  the  anus,  on  the 
scrotum,  in  the  glutc^al  folds),  continually  moist,  in  consequence 
of  wliich  the  epithelium  becomes  sodden. 

Appearance.  A  somewhat  elevated,  flat  macule,  covered  with 
a  dirty  whitish,  offensive  exudation. 


208  ESSENTIALS    OF    SURGERY.  - 

Give  the  treatment  of  secondary  syphilis. 

Mercury ;  hydrarg.  prot.  iodid.  gr.  |  three  times  daily,  guard- 
ing the  bowels  by  opium.  Increase  the  dose  gradually  till  the 
patient  exhibits  tlie  offensive  breath  or  the  beginning  mouth 
tenderness  of  ytyalism..  Then  cut  the  daily  quantity  down  one- 
half,  and  continue  for  eighteen  months,  unless  new  symptoms 
appear,  when  the  dose  may  be  temporarily  increased.  After 
eighteen  months,  add  iodide  of  potassium,  and  continue  for  six 
months  or  a  year. 

Mercury  may  be  given  :  1.  By  the  stomach.  2.  By  inunction. 
3.  By  vaporization. 

By  inimdion.  Unguent,  hydrarg.  ^ss  to  5j  at  night ;  rubbed 
into  the  feet  after  they  have  been  soaked  in  hot  water.  The 
same  stockings  must  be  worn  night  and  day. 

Mucous  patches  should  be  washed  with  black  wash,  and  dusted 
with  a  powder  made  up  of  calomel  one  part,  zinc-oxide  two 
parts. 

Sore  throat  is  treated  by  astringent  gargles. 

Describe  the  tertiary  lesions  of  syphilis. 

Between  the  secondaries  and  tertiaries  proper  there  are  certain 
symptoms,  called  reminders,  which  sometimes  appear.  Among 
them  are  skin  eruptions,  enlargement  of  the  testicle,  choroiditis, 
ulceration  of  the  tongue,  disease  of  the  arteries,  and  psoriasis  of 
the  palms. 

Tertiary  lesion  of  syphilis  is  the  gumma.  This  has  no  tendency 
to  spontaneous  cure,  and  is  characterized  by  the  formation  of 
masses  of  granulation  cells,  which  commonly  infiltrate  the  sur- 
rounding tissues,  and  break  down  in  the  centre. 

A  gumma  may  break  down,  leaving  an  ulcer,  or  may  be  ab- 
sorbed,  \e?ixmg  fibroid  thickening  and  scarring  (syphilitic  stricture 
of  rectum  and  oesophagus,  etc.).  The  gumma  may  attack  the 
periosteum,  causing  nodes,  caries,  or  necrosis  ;  the  cutaneous 
and  mucous  surface,  causing  ulcers  on  any  part  of  the  body. 

These  ulcers  of  tertiary  syphilis  are  asymmetrical,  and  are  not 
contagious. 


VENEREAL    DISEASES.  209 

Give  the  treatment  of  tertiary  syphilis. 

Mercury  and  potassium  iodide^  or  iodide  of  potassium  alone  or 
combined  with  tonics.  Commence  with  ten  grains  of  potassium 
iodide  three  times  a  day,  gradually  increasing  the  dose  till  the 
desired  effect  is  accomplished. 

What  are  the  characteristics  of  a  tertiary  ulcer  ? 

Begins  as  a  gumma  or  lump^  which,  when  it  breaks,  exposes  a 
gray  slough,  surrounded  by  granular  tissues.  The  edges  are 
rounded  and  sharply  cut.  Other  signs  of  syphilis  can  be  found. 
The  affection  yields  to  specific  treatment. 

Syphilitic  leg  ulcers  usually  involve  the  upper  third. 

What  is  congenital  syphilis? 

Syphilis  transmitted  to  the  foetus  through  the  spermatozoa  of 
the  father,  or  the  ovum  of  the  mother. 

What  are  the  characteristics  of  congenital  syphilis  ? 

Manifestations  are  rare  before  four  to  six  weeks  after  birth  ; 
then  there  may  be  secondaries,  as  snuffles  or  coryza,  macular  or 
papular  eruptions,  mucous  patches,  ulcerations  about  the  mouth 
and  lips  (rhagades),  stomatitis,  which,  by  its  effect  upon  the 
dental  sacs  of  the  permanent  teeth,  causes  the  subsequent  de- 
velopment of  Hutchinson's  teeth.  After  some  years,  tertiaries 
develop.  These  commonly  take  the  form  of  interstitial  keratitis, 
and  gummatous  developments. 

Describe  Hutchinson's  teeth. 

The  upper  permanent  median  incisors  chiefly  show  this  lesion, 
which  consists  in  a  dwarfing  of  the  entire  tooth,  an  extreme 
diminution  in  its  free  end,  and  a  narrowing  of  the  cutting  edge, 
with  a  central  notch  or  crescent. 

Give  the  treatment  of  hereditary  syphilis. 

Upon  the  same  lines  as  the  acquired  secondaries.  Mercury  best 
given  by  inunction,  gr.  x.  unguent,  hydrarg.  being  rubbed  over 
the  abdomen  and  covered  by  the  belly-band  every  night.  Stop 
mercury  shortly  after  disappearance  of  symptoms.  Prevent  a 
non-infected  woman  from  suckling  the  child. 

Tertiaries.     Mercury  and  iodide  with  tonics. 
14 


210  ESSENTIALS    OF    SUKGERY. 

What  is  Colles's  law  ? 

A  syphilitic  child  suckled  by  its  mother  will  not  infect  her, 
though  she  be  [apparently)  free  from  venereal  disease. 


Chancroid. 

What  is  a  chancroid? 

Chancroid  is  a  local  ulceration,  caused  by  contact  with  the 
secretions  of  a  similar  ulcer. 

What  are  the  characteristics  of  chancroids  ? 

1.  JVb  period  of  incubation.  Appears  in  from  three  to  five 
days ;  first  as  a  papule,  then  a  vesicle  or  pustule,  very  shortly 
an  ulcer. 

2.  Usually  multiple. 

3.  liiflaynmatoivj  in  type,  with  punched-out  edges,  irregular 
sloughing  surface,  and  abundant  discharge. 

4.  Monoganylionic  and  unilateral  lymphatic  involvement. 
May  be  simple  inflammatory  enlargement,  or  virulent  bubo  from 
direct  absorption  and  suppuration. 

5.  Autoinoculable. 

6.  Not  indurated. 

7.  JSTot  followed  by  secondaries. 

How  may  a  chancroid  be  complicated  ? 

Phagedenic  ulceration.  Characterized  by  very  rapid  and  exten- 
sive sloughing. 

Serpiginous  ulceration.  Characterized  by  slow  but  persistent 
extension. 

Phimosis.     Paraphimosis. 

Give  the  treatment  for  chancroids. 

1.  Cauterize  with  hot  iron,  sulphuric  or  nitric  acid.  Dress 
with  black  wash  or  iodoform. 

2.  Cleanse  thoroughly  with  acid,  nitric,  ^ss,  aq.  foviij.  Dust 
with  iodoform,  or  zinc  oxide  one  part,  bismuth  two  parts. 

Bubo.  Try  to  abort  by  blisters,  iodine  around  the  inflamed 
area,  or  pressure  by  means  of  a  salt  or  shot-bag.  If  it  sup- 
purates, open.     If  it  is  a  simple  inflammatory  bubo,  it  quickly 


VENEREAL    DISEASES.  211 

heals  ;  if  it  is  chancroidal,  it  has  no  tendency  to  heal,  but  must 
be  thoroughly  cauterized.  After  operation  pack  with  iodoform 
gauze  and  dress  antiseptically. 

Phagadenic  idceration.  Remove  slough  and  thoroughly  cauterize. 
Continuous  warm  bath  is  frequently  curative.  Internally,  tonics, 
opium  and  iron,  rich  food,  and  alcoholic  stimulants. 

Serpiginous  ulceration.  Repeated  applications  of  the  actual 
cautery  to  the  entire  diseased  surface,  together  with  nourishing 
and  stimulating  internal  treatment. 

What  is  primary  bubo  or  bubon  d'emblee  ? 

A  simple  adenitis  resulting  from  mechanical  irritation.  It  is 
seen  at  times,  after  coitus,  when  there  is  no  taint  of  chancroid, 
gonorrhoea,  or  syphilis. 

Gonorrhoea. 

Describe  the  urethra. 

Lengthy  8  to  9  inches. 

Three  portions.    Spongy,  memhranous,  and  prostatic. 

Spongy  portion.  6  inches  long  from  meatus  to  anterior  layer 
of  triangular  ligament.  Meatus  narrowest  portion  of  urethra. 
Lacuna  magna,  a  large  raucous  follicle  1^  inches  from  meatus  on 
the  upper  surface  of  urethra  ;  its  opening  is  directed  forward 
and  may  catch  instruments.  Glandular  and  bulbous  parts  of  the 
spongy  urethra  somewhat  dilated. 

Membranous  portion,  f  inch  long.  From  apex  of  prostate  to 
beginning  of  spongy  portion,  between  the  two  layers  of  the  tri- 
angular ligament,  1  inch  below  pubic  arch.  Except  meatus,  the 
narrowest  part.     Embraced  by  compressor  urethrse  muscle. 

Prostatic  portion.  1^  inches  long.  Widest  and  most  dilatable 
part;  passes  through  prostate  near  its  upper  surface. 

What  is  gonorrhoea  ? 

Gonorrhoea  or  clap  is  a  contagious  (probably  specific)  inflamma- 
tion attacking  mucous  membranes,  particularly  those  of  the 
genito-urinary  tract. 

Cause.  Direct  contagion  (genococcus).  Urethritis,  identical 
with  gonorrhoea,  is  developed  by  contact  with  retained  and  foul 


212  ESSENTIALS    OF    SURGERY. 

discharges  (leucorrhoea),  or  other  irritants.  It  begins  in  the 
male  usually  in  the  fossa  navicularis,  and  passes  backward.  In 
the  female  it  begins  in  the  vulva  and  vagina. 

Name  the  clinical  varieties  of  gonorrhoea. 

1,  Acute  inflammatory  (typical).  2.  Subacute  or  catarrhal. 
3.  Irritative  or  abortive. 

What  are  the  stages  of  an  acute  attack  ? 

First,  or  increasing  stage.  Second,  or  stationary  stage.  Third, 
or  subsiding  stage. 

What  are  the  first  symptoms  of  gonorrhoea  ? 

Usually,  in  three  to  five  days,  there  is  a  tickling  sensation  at 
the  meatus,  which  is  changed  to  a  burning  at  the  next  urina- 
tion. On  examination,  the  lips  of  the  meatus  are  somewhat 
reddened  and  everted,  and  there  is  a  slight  muco-purulent  dis- 
charge. In  a  very  short  time  (twelve  to  twenty-four  hours)  the 
patient  reaches  the  well-developed  first  stage. 

Give  the  symptoms  of  the  increasing  stage. 

1.  Ardor  urinae.  2.  Profuse  purulent  discharge.  3.  Chordee 
(painful  erections).     4.  Frequent  urination. 

What  are  the  complications  of  the  first  stage  ? 

1.  Balanitis^  or  inflammation  extending  over  the  glans  penis. 

2.  Balano-posthitis.  Inflammation  of  the  mucous  layer  of  the 
foreskin. 

3.  Phimosis,  or  inability  to  retract  the  foreskin,  from  oedema- 
tous  swelling. 

4.  Paraphimosis.  The  retracted  and  swollen  foreskin  cannot 
be  brought  forward. 

The  first  stage  lasts  about  one  week. 

Give  the  symptoms  and  complications  of  the  second  stage. 

The  inflammation  gradually  extends  backward.  There  is  a 
continuance  of  the  symptoms  of  the  first  stage,  with  possibility 
of  the  following  complications  : — 

Follicular  abscesses,  appearing  as  small,  round,  tender  tumors 
along  the  floor  of  the  urethra.  They  may  open  either  internally 
or  externally. 


VENEREAL    DISEASES.  213 

Periurethral  abscess.  Favorite  seat  about  the  fossa  navicularis 
and  the  anterior  membranous  portion  of  the  urethra,  where  the 
disease  is  most  persistent. 

Lywjjhaiifjitis.  Dependent  usually  on  retention  of  discharge 
beneath  prepuce.  Thick,  tender,  reddened  cord-like  line  along 
dorsum  of  penis. 

Bubo.  One  gland  affected  ;  may  undergo  resolution,  or  may 
suppurate. 

Cowperitis.  Characterized  by  very  intense  throbbing  pain. 
Painful  urination,  especially  at  the  end  of  the  act  (compressor 
urethrse  m.),  and  the  detection  of  the  hard,  inflamed  glands  by 
examination  of  the  perineum. 

Second  stage  lasts  one  or  two  weeks. 

Give  the  symptoms  and  complications  of  the  stage  of  subsidence. 

Symptoms  as  of  the  other  stages.  They  may  be  complicated 
by  exAdidymitis^  characterized  by  pain  of  an  intense  and  sicken- 
ing character  passing  along  the  cord  to  the  loins,  sv:elUngs,  out- 
lined at  the  back  of  the  scrotum  and  considerable  in  extent,  and 
tenderness;  there  is  nearly  always  fever. 

Bescribe  subacute  or  catarrhal  gonorrhoea. 

Occurs  usually  in  persons  who  have  had  previous  attacks.  Is 
characterized  by  very  free  discharge^  with  absence  of  other  symp- 
toms or  complications.  Yields  rapidly  to  treatment,  but  does 
not  entirely  disappear,  a  drop  or  two  of  muco-pus  being  dis- 
charged daily. 

What  are  the  complications  of  subacute  gonorrhoea  ? 

Gonorrhoeal  rheumatism  or  urethral  synovitis.  Characterized  by 
slight  constitutional  symptoms  and  a  rapid  development  of  syno- 
vitis in  knee,  ankle,  wrist,  or  elbow. 

Gonorrhoeal  ophthalmia  (sclerotitis,  iritis),  or  conjunctivitis. 

Describe  irritative  or  abortive  gonorrhoea. 

The  symptoms  are  those  of  beginning  acute  gonorrhoea,  i.  e., 
redness,  pouting,  and  tingling  or  itching  at  the  meatus,  with  a 
very  slight  mucous  discharge.  The  disease  does  not  advance  be- 
yond this  point.  These  symptoms  may  persist  for  several  days, 
then  disappear.     No  complications,  no  sequelae. 


21rl:  ESSENTIALS    OF    SURGERY. 

Give  the  treatment  of  g-onorrhoea. 

Rest  in  bed,  if  possible,  on  a  diet  of  skimmed  milk^  giving  plenty 
of  bland  liquids,  such  as  ApoUinaris  water,  soda  water,  etc.  Keep 
the  bowels  open.  To  make  the  urine  alkaline,  and  to  act  as  a 
sedative,  give — 

IJ..    Tr.  aconit.  rad.  gtt.  xvj. 

Pot.  brom.  5iij. 

Infus.  pareir.  brav.  fSviij. 
S.    fsss  in  aq.  every  two  hours. 

For  ardor  urince  give  the  above  prescription.  Immerse  the 
penis  in  hot  water  during  urination.  Wrap  the  organ  in  cloths 
saturated  with — 

Tr.  aconit.  rad., 

Tr.  opii, 

Alcohol,  aa  Sj. 

Liq  plumb,  subacetat.  dil.  fSiij. 

Chord.ee.  Bromide  of  potassium  till  drowsiness  is  produced  ; 
a  double  dose  on  retiring,  repeated  during  the  night. 

If  the  patient  wakes  with  chordee,  camphor  gr.  iij,  opium 
gr.  j,  as  a  suppository  or  hypodermics  of  morphia  (gr.  5)  injected 
into  the  perineum. 

When  the  disease  has  reached  its  height  and  is  declining^  give 
capsules  of  cubebs  and  copaiba,  TTlxx  of  each,  every  two  hours. 

Injections  may  now  be  used — 

Bismuth,  subnit.  5j. 
G-lycerin,  foij. 
Aq.  ros.  q.  s.  fgiv. 

Followed  in  a  few  days  by — 

Zinc,  sulph.  gr.  viij. 
Morph.  sulph.  gr.  j. 
Aq.  ros.  fgiv. 

Gradually  stop  injections  and  internal  medication. 

What  are  the  causes  of  chronic  urethral  discharge  ? 

1.  Urethral  catarrh. 

2.  Chronic  gonorrhoea^  a  localization  of  the  disease,  producing 
a  granular  and  somewhat  ulcerated  surface. 

3.  Stricture  of  urethra.     The  usual  cause  of  gleet. 


VENEREAL    DISEASES.  215 

How  can  the  nature  o£  chronic  urethral  discharge  be  deter- 
mined ? 

Urethral  catarrh  immediately  follows  gonorrhoea,  and  presents 
no  symptoms  beyond  a  thin,  watery  discharge. 

Chronic  gonorrhoea  discharges  creamy  pus,  is  greatly  aggravated 
by  any  excess.  There  is  some  burning  at  urination,  and  at  times, 
chordee.  It  is  generally  found  about  the  navicular  fossa  and  the 
bulbo-membranous  portion  of  the  urethra.  Examination  by 
a  bulbous  bougie  detects  a  rough,  tender  spot,  and  pus  and  blood 
may  be  brought  away  upon  the  shoulder  of  the  instrument. 

Gleetfrom  stricture  appears  some  time  after  subsidence  of 
gonorrhoea.  It  is  characterized  by  muco-purulent  discharge, 
and  frequent  urination,  with  itiqnrfect  cut  off.  On  passing  a  bul- 
bous bougie  narrowing  is  detected. 

Give  the  treatment  of  chronic  urethral  discharge. 

Urethral  catarrh.  Constitutional  treatment,  open  air,  nourish- 
ing diet,  exercise,  regular  living,  iodide  of  iron. 

Chronic  gonorrhoea.  Locate  the  spot  by  means  of  the  bulbous 
bougie.  Apply,  b}'-  means  of  the  prostatic  syringe,  a  one-quarter 
per  cent,  solution  of  nitrate  of  silver,  increasing  the  strength  if 
there  is  no  pain  ;  follow  by  astringents,  zinc  or  copper. 

Gleet.  Gradual  dilatation  with  steel  sounds,  passed  twice 
weekly,  till  the  urethra  is  of  normal  size  (28  to  32,  depending  on 
the  size  of  the  penis). 

Give  the  treatment  for  complications  of  gonorrhoea. 

Balanitis.  Wash  carefully  four  times  daily,  and  dust  with 
iodol,  iodoform,  or  a  powder  of  bismuth  and  opium. 

Balano-posthitis.  Careful  washing.  If  great  swelling,  envelop 
in  lead  water  and  laudanum. 

Phimosis.  Injections  beneath  the  prepuce  of  soap  and  water, 
then  water,  finally  lead  water  and  laudanum ;  wrap  the  penis 
in  cloths  wet  in  lead  water  and  laudanum.  Incision  or  circum- 
cision may  be  necessary. 

Paraphimosis.  Reduce  by  manipulating,  or,  covering  the 
glans  with  lint,  envelop  it  from  before  backward  in  an  elastic 
band,  slip  a  director  under  the  constriction,  remove  the  elastic 


216 


ESSENTIALS    OF    SURGERY. 


wrapping,  and  reduction  may  be  effected.  Incision  if  other  means 
fail. 

Prostatitis,  cystitis  (see  under  these  headings). 

epididymitis.  Rest  in  bed,  elevation  of  scrotum,  application 
of  evaporating  lotions,  abstraction  of  six  or  eight  ounces  of  blood 


Fig.  49. 


Fig.  50. 


E.  R.  The  constricting  ring  in 
paraphimosis. 


R.  R.  The  constricting  ring  in 
phimosis. 


by  leeches  placed  over  the  cord.  Open  the  bowels,  give  morphia 
hypodermically,  bromide  of  potassium  and  aconite  internally. 
If  swelling  increases  and  pain  is  intense,  puncture  the  tunica 
albuginea  with  a  tenotome.  When  acute  inflammatory  symp- 
toms begin  to  subside,  strap  the  testicle.  ^ 
Gonorrhoeal  rheumatism.  Iodine  and  splint  to  the  joint,  to- 
gether with  firm  pressure  ;  very  full  doses  of  quinine  (grains  xl. 
daily),  small  doses  of  mercury,  generous  diet. 

Give  the  treatment  of  gonorrhoea  in  the  female. 

Usual  form,  vidvo-vaginitis,  may  extend  to  the  urethra,  the 
womb,  the  Fallopian  tubes  (gonorrhoeal  salpingitis),  and  the 
ovaries. 

Best  in  bed,  milk  diet,  free  motion  from  the  bowels,  repeated 
daily  washings  with  strong  sod.  bicarb,  solutions,  followed  by 
thorough  application  of  liq.  argent,  nit.  grains  Ix  to  the  ounce. 
General  hot  baths,  or,  in  case  of  vaginitis,  every  two  hours  inject 


STRICTURE    OF    THE    URETHRA.  217 

bicarbonate  of  soda  solution,  Oj,  follow  with  aq.,  Oj,  finally 
acetate  of  lead  ^iij  (teaspoonful).in  the  pint  of  water.  Keep  the 
mucous  surfaces  apart  by  packing  with  absorbent  cotton  con- 
tainins;  lead  acetate. 


Urethral  Deformities. 

Describe  epispadia. 

Epispadia,  or  deficiency  of  the  urethral  roof,  may  be  complete 
ov  partial.  Complete  epispadia  is  usually  associated  with  ex- 
strophy of  the  bladder. 

Treatment.  Freshen  the  edges  on  either  side  of  the  urethral 
floor,  and  bring  them  together  over  a  catheter  by  means  of  quill 
sutures  ;  flaps  may  be  transplanted. 

Describe  hypospadia. 

Hypospadia,  or  deficiency  of  the  urethral  floor,  may  occur  at 
the  base  of  the  frenum,  or  at  the  junction  of  the  penis  and- 
scrotum. 

Treatment.  Kestore  the  natural  passage  ;  freshen  the  edges  of 
the  abnormal  opening,  and  close  or  cover  by  transplanted  flaps. 


Stricture  of  the  Urethra. 

What  is  stricture  of  the  urethra? 

True  or  organic  stricture  is  2Jerraanent  narrowhig  of  the  urethral 
canal  at  one  or  more  places,  due  to  disease,  injury,  or  congenital 
defect.     There  are  also  spasmodic  and  congestive  strictures. 

What  are  the  causes  of  stricture  ? 

Gonorrhoea,  traumatism,  ulceration,  and  masturbation. 

Give  some  varieties  of  organic  urethral  stricture. 

In  regard  to  cause:  1.  Idiopathic.  2.  Traumatic.  3.  In- 
flammatory. 

In  regard  to  anatomical  appearances — 

1.  Bridle  stricture.  A  band  of  lymph,  attached  only  by  its  ends, 
stretching  across  the  uretlira. 


218  ESSENTIALS    OF    SURGERY. 

2.  Annular.  A  circular  constriction  as  though  a  string  were 
tied  about  the  urethra. 

3.  Indurated  annular. 

4.  Cartilaginous. 

In  regard  to  the  possibiUty  of  passing  instruments  strictures 
are  classed  as  permeable  and  impermeahle. 

In  regard  to  their  behavior  on  manipulation,  they  may  be  sim- 
ple, irritable,  contractile  or  recurring. 

What  are  the  favorite  seats  of  stricture  ? 

1.  Anterior  part  of  the  urethra.  2.  Just  in  front  of  the  mem- 
branous portion  of  the  urethra.  Strictures  are  never  found  in 
the  prostatic  portion  of  the  urethra. 

What  are  the  consequences  of  an  untreated  stricture? 

Hyperaemia  and  inflammation  about  the  stricture.  Dilation 
and  thinning  of  the  urethral  walls  behind.  Hypersecretion  and 
gleet.  Ulceration  m?iy  take  place,  followed  by  extravasation, 
abscesses,  and  fistulse.  From  constant  straining,  bladder  be- 
comes thickened,  hypertrophied,  and  sacculated.  Urine  is 
retained  and  ferments  ;  cystitis  may  reach  a  high  grade.  The 
inflammation  passes  along  the  ureters,  involves  the  pelves  of 
the  kidneys,  and  may  cause  death  by  suppurative  pyelitis,  or 
nephritis. 

What  are  the  symptoms  of  organic  strictures  of  the  urethra? 

Gleety  discharge,  especially  in  the  morning  ;  increased  frequency 
of  urination,  with  some  pain,  twisting,  forking,  or  diminution  in 
the  size  of  the  stream.  Retention  may  be  the  first  and  only  sign. 
Later  symptoms  are  due  to  involvement  of  other  organs  ;  hemor- 
rhoids frequently  result  from  constant  straining. 

How  do  you  diagnose  strictures  ? 

By  examination  of  the  urethra  with  bulbous  bougies.  Com- 
mence with  medium-sized  bulbous  bougie  and  increase  the  size 
till  decided  resistance  is  experienced  ;  or  if  the  first  tried  will 
not  pass,  diminish  the  size  till  one  finally  enters  the  bladder, 
marking  on  its  stem  the  point  where  resistance  begins  ;  slowly 
withdraw  from  the  bladder,  marking  again  the  point  where 
resistance  begins  ;  this  will  give  both  the  calibre  and  the  iddth 


STRICTURE    OF    THE    URETHRA.  219 

of  the  stricture.     If  the  obstruction  is  more  than  six       Fig.  51. 
inches  from  the  meatus,  it  is  probably  an  enlarged 
prostate.     The  possibility  of  spasm  or  the  catching 
of  the  bulb  of  the  bougie  in  a  lacuna  or  at  the  tri- 
angular ligament  must  be  borne  in  mind. 

What  special  points  must  be  observed  in  passing  a 
bougie  or  catheter  ? 

1.  See  that  the  instrument  is  clean,  smooth,  and, 
if  it  is  a  catheter,  permous. 

2.  Warm  and  oil. 

3.  Place  the  patient  on  his  back  with  thighs  flexed. 

4.  Bear  in  mind  the  course  of  the  urethra,  keep 
the  catheter  in  the  middle  line,  stretch  the  penis 
forward  and  upward,  and  use  no  force. 

"What  difficulties  may  occur  in  passing  the  catheter? 

1.  It  may  catch  in  a  fold  of  mucous  membrane  or 
in  a  lacuna.  Avoid  by  keeping  the  point  on  the 
floor  of  the  urethra  at  first,  then  along  its  roof. 

2.  It  may  catch  where  the  urethra  enters  the  tri- 
angular ligament.  Withdraw  a  little  and  keep  the 
point  of  the  instrument  along  the  roof  of  the  urethra. 

3.  It  may  make  a  new  false  passage,  or  enter  one 
already  made.  Denoted  by  a  sudden  slipping  of  the 
instrument,  fjain,  and  detection  of  the  point  of  the 
catheter  outside  of  the  urethra  by  rectal  examina- 
tion. The  handle  of  the  bougie  is  deflected  from  the 
middle  line,  no  urine  escapes,  the  point  is  not  freely 
movable,  and,  if  the  false  passage  is  recent,  there  will  bulbous 
be  free  bleeding.  bougie. 

How  do  you  treat  false  passage  ? 

Withdraw  the  instrument  at  once,  and  make  no  further  effort 
to  pass  it  for  one  or  two  weeks.  Infiltration  of  urine  rarely  takes 
place,  the  passage  healing  promptly. 

What  constitutional  effects  may  follow  the  passage  of  an  in- 
strument ? 

Hfematuria,  due  to  reflex  congestion,  syncope,  rigors,  urethral 
fever,  sujjpression  of  urine,  ])ytemia. 


220 


ESSENTIALS    OF    SURGERY, 


Fiff.  52. 


How  may  the  danger  from  these  sequelae  he  lessened? 

Pass  instrument  with  the  patient  in  the  recumbent  position  ; 
give  12  grains  of  quinine  an  hour  before  treating;  inject  V(\x 
to  XX  of  a  1  per  cent,  solution  of  cocaine  into  the  bulbous  por- 
tion of  tlie  urethra  by  means  of 
Fig.  53.  i]^Q  prostatic  syringe  a  few  min- 

utes before  passing  an  instru- 
ment. Keep  the  patient  in  bed 
six  to  twenty-four  hours  after 
the  instrument  is  used. 

How  do  you  treat  strictures? 

Strictures  may  be  treated  by 
— 1.  Dilatation.  This  may  be 
intermittent^  continuous^  on  forci- 
ble (splitting).  2.  Urethrotomy^ 
or  cutting  ;  either  internal  or  ex- 
ternal. 3.  Excision.  4.  Electro- 
lysis. 

How  do  you  get  through  a  tight 
stricture  ? 
Try  a  small,  soft,  olive-point- 
ed  catheter  or    a   small    steel 
sound.     That    failing,    electro- 
lysis may  succeed.    Finally  sev- 
eral filiforms  should  be  passed 
into  the  urethra,  and  each  ma- 
nipulated in  turn  till  one  passes 
into  the  bladder ;  this  may  be 
threaded  upon  a  railroad  cathe- 
ter and  the  latter  forced  through  the  stricture  with- 
out fear  of  making  a  false  passage. 

Describe  intermittent  dilatation. 

The  calibre  of  the  stricture  having  been  determined, 
the  largest  flexible  bougie  which  will  pass  through  it 
is  introduced,  and  allowed  to  remain  in  the  urethra 
for  four  or  five  minutes  before  withdrawing.     At  the 


Olive- 
pointed 

soft 
catheter. 


Filiform  threaded 
upon  a  railroad  cath- 
eter. 


STRICTURE    OF    THE     URETHRA 


221 


Fig.  54. 


next  attempt  a  larger  instrument  is  used,  till  28  to  30  French 
will  readily  pass  in  ;  three  days  should  elapse  between  each 
dilation.  This  is  the  best  and  safest  of  all  methods  of  treat- 
ment for  the  simple  forms  of  stricture. 

Describe  continuous  dilatation. 

The  patient  is  put  to  bed  ;  a  flexible  ca- 
theter is  passed  through  the  stricture  into 
the  bladder,  and  allowed  to  remain  for  one 
or  two  days,  when  it  is  replaced  by  a  larger 
one  ;  continue  in  this  way  till  the  stric- 
ture is  fully  dilated. 

Under  what  circumstances  may  continu- 
ous dilatation  be  employed? 

Where  there  is  great  difficulty  in  pass- 
ing an  instrument,  or  where  the  stricture 
is  irritable  or  contractile. 

(The  majority  of  surgeons  condemn 
rapid  dilatation  or  siMtting. ) 

Describe  internal  urethrotomy. 

By  means  of  a  guarded  knife  the  stric- 
ture is  cut  entirely  through.  In  tight  stric- 
tures a  guide  or  small  instrument  is  passed, 
which  can  be  threaded  on  the  urethrotome, 
and  the  latter  can  then  be  made  to  cut  its 
way  inward  without  fear  of  its  going 
astray.  Pass  a  bulbous  bougie  to  see  that 
the  stricture  has  been  completely  divided, 
in  which  case  there  is  no  fear  of  urinary 
extravasation.  In  four  days  pass  a  full- 
sized  soft  catheter. 

What  strictures  are  properly  subject  to 
internal  urethrotomy? 

Strictures  in  front  of  the  scrotum,  and 


strictures. 


Railroad  urethrotome. 
(White.) 


222 


ESSENTIALS    OF    SURGERY. 


Describe  external  perineal  urethrotomy  with  a  guide  (Syme's 
method). 

Lithotomy  position.     The  groove  of  a  Syme's  staff  is  passed 
through  the  stricture  till  its  shoulder  is  caught  in  the  beginning 
of  the  narrowing.     A  1^  inch  incision  is  made 
Fig.  55,  in  the  median  line  of  the  perineum,  the  groove 

of  the  staff  is  found,  the  knife  slipped  into  it 
behind  the  stricture,  and  the  latter  divided  by 
pressing  the  cutting  edge  forward.  A  director 
is  passed  into  the  bladder,  and  a  14  (English) 
soft-rubber  catheter  passed  per  urethram. 
This  catheter  is  not  left  in,  but  is  passed  every 
three  or  four  days  till  the  wound  is  healed. 

What  strictures  call  for  external  perineal  ure- 
throtomy with  a  guide  ? 

Dense  cartilaginous  strictures,  or  irritable 
and  contractile  strictures  when  complicated  by 
j)erineal  fistulae. 

How  do  you  treat  impermeable  strictures  ? 

By  Wheelhouses's  modification  of  perineal 
section. 

By  Cock's  operation  of  perineal  section,  or 
tapping  the  urethra  at  the  apex  of  the  prostate. 

What  is  Wheelhouses's  modification  of  perineal 
section  ? 

The  urethra  is  opened  half  an  inch  in  front 

of  the  stricture,  when  the  latter  can  be  exposed 

to  view,  entered  by  a  probe,  and  divided.     A 

broad   director    introduced    into  the   bladder 

Syme's  staff.         guides  a  flexible  catheter  passed  through  the 

meatus.     The  catheter  is  left  in  for  three  ot 

four  days.     In  this  operation  the  Wheelhouses  staff  is  used  ;  this 

is  practically  a  director,  grooved  to  within  half  an  inch  of  its 

end,  and  terminating  in  a  blunt-hooked  projection. 


STRICTURE    OF    THE     URETHRA.  223 

What  are  the  indications  for  Wheelhonses's  modification  of 
perineal  section  ? 

Dense  cartilaginous,  or  irritable  and  contractile  strictures, 
which  are  impermeable. 

Describe  Cock's  perineal  section. 

Lithotomy  position.  Left  forefinger  in  rectum,  the  point  ap- 
plied to  apex  of  prostate.  Pass  a  long,  straight  knife,  with  its 
back  towards  the  rectum,  in  the  middle  line  beneath  the  bulb, 
so  that  it  may  enter  the  membranous  portion  of  the  urethra  ;  a 
director  is  then  introduced,  and  guided  by  it  a  soft  catheter  is 
passed  into  the  bladder.  The  urethra  is  opened  behind  the 
stricture,  the  latter  not  being  touched. 

Indicated  in  case  of  impermeable  stricture  complicated  by 
urinary  retention^  or  in  case  of  urethral  rupture. 

Describe  rupture  of  the  urethra. 

Cause.     Violence.     May  be  torn  partly  or  completely  across. 
Seats.     Just  in  front  of,  or  just  behind  the  triangular  liga- 
ment. 

Give  the  symptoms  of  ruptured  urethra. 

Behind  triangular  ligament  as  in  rupture  of  bladder.  Inability 
to  pass  water.  Blood  and  urine  on  catheterization.  Infiltration 
behind  symphysis. 

In  front  of  triangular  ligament.  Tumor  in  perineum  ;  blood 
per  urethram  ;  inability  to  pass  water. 

How  do  you  treat  ruptured  urethra  ? 

Pass  in  a  catheter.  If  there  is  any  difficulty  in  introducing, 
do  an  external  perineal  urethrotomy,  passing  a  catheter  after 
two  or  three  days,  and  at  regular  intervals  afterwards.  If  ure- 
thra completely  torn  across,  unite  by  catgut  suture. 

Describe  urinary  extravasation. 

If  extravasation  takes  place  from  the  prostatic  portion  of  the 
urethra,  the  symptoms  and  treatment  are  the  same  as  for  rup- 
tured bladder.  If  from  the  membranous  portion,  there  will  be 
at  first  a  hard  lump  in  the  perineum,  as  the  anterior  layer  of  the 
triangular  ligament  gives  way,  the  extravasation  will  take  the 


224  ESSENTIALS    OF    SURGERY. 

course  common  in  all  anterior  extravasations,  that  is,  into  the 
scrotum  and  up  upon  the  abdominal  parietes,  not  descending 
upon  the  thighs  (attachments  of  deep  layer  of  superficial  fascia). 
The  symptoms  are  characteristic  ;  if  the  patient  has  been  suffer- 
ing from  retention,  he  may  suddenly  experience  a  sense  of 
relief,  followed  shortly  by  burning  pain  in  the  perineum  and  in- 
flammatory fever,  which  quickly  becomes  typhoid  in  type.  There 
are  redness,  swelling,  oedema,  and  early  sloughing  of  the  infil- 
trated area. 

The  treatment  is  perineal  section,  tapping  the  source  of  extrava- 
sation. Long  incision  should  follow  up  the  subcutaneous  infil- 
tration. 

Diseases  of  the  Prostate. 

Name  the  surgical  affections  of  the  prostate  gland. 

Inflammation;  may  he  acute,  chronic,  or  complicated  by 
abscess.  Hypertrophy.  Atropihy.  Tubercle.  Malignant  disease^ 
sarcoma  in  the  young,  carcinoma  in  the  old. 

Give  the  symptoms  of  acute  inflammation  of  the  prostate. 

Usual  cause — gonorrhoea  or  stricture. 

There  is  pain  at  the  neck  of  the  bladder,  increased  by  defecation 
and  by  micturition,  especially  towards  the  end  of  the  act. 

The  water  is  passed  frequently .  On  examination  per  rectum  the 
prostate  is  felt  as  a  hot,  tender  enlargement.     There  \^  fever. 

Termination.     Resolution,  abscess,  or  chronic  inflammation. 

Give  the  treatment  of  acute  prostatitis. 

Open  bowels  freely.  Render  the  urine  bland  by  full  doses  of 
alkaline  carbonates.  Apply  leeches  to  the  perineum,  followed 
by  hot  fomentations,  poultices,  and  hot  hip-baths.  If  there  is  re- 
tention, a  catheter  should  be  passed.  If  an  abscess  forms,  open 
the  perineum  in  the  middle  line. 

Describe  chronic  prostatitis. 

Causes.     An  acute  attack,  stricture,  masturbation,  gout. 
It  is  characterized  by  constant  aching  pain  in  the  perineum, 
aggravated  by  defecation  and  urination.     There  is  a  discharge, 


DISEASES    OF    THE    PROSTATE.  225 

like  the  white  of  an  egg,  appearing  during  defecation  and  at  the 
beginning  of  urination.  There  is  frequent  urination  witli  imper- 
fect cut  off,  and  cystitis. 

Treatment.  Avoidance  of  stimulants,  sexual  indulgence,  or 
violent  exercise.  Bowels  must  be  kept  open.  Tonics.  Sea 
bathing.  Fugitive  blisters  to  perineum.  By  means  of  the  pros- 
tatic syringe  nitrate  of  silver,  TTLv  of  a  two  per  cent,  solution, 
applied  to  the  diseased  area. 

Give  the  symptoms  of  enlarged  prostate. 

This  is  a  disease  of  advanced  life.  It  is  characterized  by 
greatly  increased  frequency  of  micturition,  especially  at  night, 
by  loss  of  force  in  the  stream,  with  difficulty  and  sloxaness  in  start- 
ing it,  by  a  sense  of  fulness  about  the  rectum.  Yery  frequently 
there  are  hemorrhoids  from  straining.  Fermentation  of  retained 
urine  with  cystitis  may  follow.  Finally,  retention  with  overflow, 
or  even  absolute  retention  may  result. 

How  do  you  diagnose  an  enlargement  of  the  prostate  ? 

The  finger  in  the  rectum  will  recognize  most  enlargements. 
In  case  there  is  projection  of  the  middle  lobe  into  the  urethra 
a  silver  catheter  will  meet  with  an  obstruction,  more  than  seven 
inches  from  the  meatus,  which  is  only  overcome  by  greatly  de- 
pressing the  handle  of  the  instrument.  An  ordinary  catheter 
may  not  be  long  enough  to  reach  the  bladder. 

How  do  you  treat  chronic  enlargement  of  the  prostate  ? 

Immediately  after  urination  pass  a  soft  catheter.  If  addi- 
tional water  can  be  drawn,  it  is  proof  that  the  obstruction  pre- 
vents thorough  emptying  of  the  bladder.  Give  the  patient  a 
soft  catheter,  elbowed  if  the  middle  lobe  is  enlarged,  and  let 
him  pass  it  every  night  on  retiring.  Commence  this  treatment 
bcfwe  cystitis  appears.  For  more  aggravated  cases,  where  the 
bladder  is  irritable  and  sacculated,  the  pain  unbearable,  the 
patient  absolutely  unable  to  pass  water  without  a  catheter,  but 
suffering  intensely  each  time  the  instrument  is  passed,  drain  the 
Uadd/ir  by— 1.  Perineal  section.  2.  Suprapubic  tapping  and 
retention  of  canula.  3.  Suprapubic  incision  with  excision  of  a 
portion  of  the  prostate. 


226  ESSENTIALS    OF    SURGERY. 

What  symptoms  denote  malignant  disease  of  the  prostate? 

Pain,  frequent  urination,  hemorriiage  per  urethram,  shreds 
of  growth  in  urine,  rapid  swelling  of  unequal  consistency,  gland- 
ular enlargements,  cachexia. 

Treatment.     Palliative. 

What  is  meant  by  bar  at  the  neck  of  the  bladder  ? 

A  ridge  due  to  hypertrophy  of  the  lateral  lobes. 


AFFECTIONS    OF    THE    BLADDER.  227 

AFFECTIONS  OF  THE  BLADDER. 

Rupture  of  the  Bladder. 

Describe  rupture  of  the  bladder. 

Causes.  Violence.  Over-distension.  May  be  intra-  or  €xtra-2)eri- 
toneal. 

Symptoms.  Pain  and  collapse,  sense  of  something  giving  wa}^, 
urgent  desire  to  urinate  without  the  power  to  do  so,  rapid  devel- 
opment of  inflammation  or  peritonitis.  Catheter  passed  just  in- 
side the  bladder  draws  hlood  only,  or  a  small  amount  of  bloody 
urine.  If  the  patient  has  passed  his  urine  immediately  before 
the  accident,  a  weak  antiseptic  solution  (boracic  acid)  may  be 
injected  into  the  bladder.  If  there  is  a  rupture,  it  cannot  be 
again  drawn  off. 

Treatment.  Insertion  of  full-sized  catheter  and  expectant,  or 
Suprapubic  Cystotomy;  opening  and  washing  out  the  peritoneal 
cavity  if  urine  has  been  extravasated  into  it,  closing  the  peri- 
toneal Vent,  and  inserting  a  drainage  tube.  After  treatment, 
patient  in  lateral  decubitus. 

What  tumors  are  found  in  the  bladder  ? 

Papilloma — most  common  benign  tumor.  Mucous  and  fibrous 
polyps,  rare.  Sarcoma.  Carcinoma,  epithelial  or  encephaloid. 
Tumors  are  usually  situated  on  the  trigone. 

Give  the  symptoms  of  bladder  tumor. 

Hsematuria,  cystitis,  pain,  the  passage  per  urethram  of  frag- 
ments of  the  growth. 

Treatment.  Benign  growths  may  be  removed  by  perineal  or 
suprapubic  operations. 

Exstrophy  of  the  Bladder. 

What  is  exstrophy  of  the  bladder  ? 

Synonyms.     Ectopion,  extroversion. 

JJefi/aitifm.     Congenital  absence  of  the  anterior  wall  of  the 


228  ESSENTIALS    OF    SURGERY. 

bladder,  together  with  the  corresponding  portion  of  the  abdomi- 
nal wall.  The  posterior  wall  of  the  bladder  projects  as  a  round, 
vascular,  red,  ulcerated  tumor,  covered  with  mucous  membrane, 
and  exposing  the  orifices  of  the  ureters. 

Treatment  consists  in  covering  in  the  defect  by  deep  and  super- 
ficial flaps,  wdiich  hav€  their  raw  surfaces  apposed,  and  offer 
both  to  the  bladder  w^all  and  externally,  skin  surfaces. 

This  deformity  is  usually  accompanied  by  epispadia. 

Cystitis, 

What  are  the  causes  of  cystitis  ? 

Cystitis,  or  inflammation  of  the  bladder,  may  be  acute  or 
chronic. 

Causes.  Mechanical  or  chemical  injury,  or  direct  extension 
(gonorrhoea). 

Give  the  symptoms  of  acute  cystitis. 

Pain^  burning,  may  be  very  severe,  located  in  the  bladder  and 
perineum.  Strangury,  a  continual  desire  to  void  urine^  which 
is  spasmodically  passed,  a  few  drops  at  a  time.  Tenderness,  well 
marked  over  the  pubes,  in  the  bladder  region.  Urine,  scanty, 
highly  colored,  containing  mucus,  blood,  and  pus.  Fever,  directly 
proportionate  to  the  grade  of  inflammation. 

Give  the  treatment  of  acute  cystitis. 

Rest  in  bed.  Diet  of  skimmed  milk,  with  carbonated  drinks. 
Bowels  soluble.  Leeches  to  perineum,  or  over  pubes.  Hot  hip- 
baths and  hot  poultices.  Alkaline  carbonates,  hyoscyamus,  morphia 
and  belladonna  suppository.  If  urine  is  ammoniacal,  the  bladder 
must  be  washed  out  with  antiseptic  lotions  (boracic  acid  gr.  iv 
to  5j) ;  this  failing,  an  external  perineal  urethrotomy  with 
drainage  of  the  bladder  is  indicated. 

Describe  chronic  cystitis. 

Symptoms  as  in  acute,  but  milder.  Urine  often  ammoniacal, 
very  offensive,  contains  large  quantities  of  ropy  mucus  and  pus. 
Mucous  membrane  thickened,  congested,  ulcerated.  Muscular 
coat  thickened,  fasciculated,  giving  the  interior  of  the  bladder  a 


AFFECTIONS    OF    THE    BLADDER.  229 

ridged  appearance.  Between  the  muscular  ridges  the  mucous 
membrane  may  be  forced  outward  by  constant  straining,  form- 
irlg  sacculations,  in  which  stones  may  form. 

Treatment.  Removal  of  cause,  where  possible.  General 
hygiene.  Milk  diet,  with  free  use  of  non-stimulating  drinks. 
Triticum  repens,  uva  ursl,  copaiba,  cubebs.  When  urine  alka- 
line, benzoic  acid.  Local  washings.  Twice  daily  with  boracic 
acid,  or  water  hot  as  it  can  be  borne.  In  severe  cases,  perineal 
cystotomy  and  drainage. 


Atony  and  Paralysis  of  the  Bladder. 

"What  is  atony  of  the  bladder  ? 

By  atony  is  implied  a  loss  of  tone  in  the  muscular  fibres  of 
the  bladder,  making  it  unable  to  expel  its  contents.  The  blad- 
der is  only  partially  emptied  at  each  micturition  ;  it  gradually 
becomes  more  and  more  full  till  the  condition  known  as  reten- 
tion with  overflow  is  developed,  simulating  incontinence.  The 
cause  of  atony  is  over-distension.;  it  may  arise  in  the  course  of 
low  fever,  from  voluntary  neglect,  or  from  urethral  obstruction. 

Treatment.  Catheter  ;  cold  douche  to  bladder  and  to  lumbar 
spine. 

Describe  paralysis  of  the  bladder. 

Cause.  Injury,  or  organic  disease  of  nervous  system,  nervous 
exhaustion.  If  the  neck  of  the  bladder  is  affected,  it  causes 
incontinence.  If  the  body  of  the  bladder  alone  is  involved,  there 
will  be  retention. 

Treatment.     Catheter,  tonics,  strychnia,  electricity. 


Hsematuria. 

How  can  you  determine  the  source  of  blood  in  the  urine? 

From  the  kidney.  Blood  is  uniformly  distributed  through  the 
urine.  From  the  bladder.  Comparatively  clear  urine  is  passed 
at  first,  followed  by  blood.  From  the  urethra.  Blood  passes  first, 
then  urine. 


230  ESSENTIALS    OF    SURGERY. 

What  surgical  affections  may  cause  renal  hemorrhage  ? 

Contusion  or  jarring,  congestion,  inflammation,  calculus,  the 
uric  acid  diathesis,  catlieterism,  malignant  disease. 

Give  the  causes  of  hladder  hemorrhages. 

Traumatism,  calculus,  inflammation,  new  growths. 

Give  the  causes  of  urethral  hemorrhages. 
Injury,  ulceration,  calculus,  erectile  growths. 

How  are  clots  removed  from  the  bladder? 

By  large  suction  catheter.  By  digesting  the  clots  in  the  blad- 
der.    By  urethrotomy  or  cystotomy. 

Retention  of  Urine. 

What  are  the  causes  of  retention  of  urine  ? 

Retention  means  simply  inability  to  pass  the  urine  from  the 
bladder.     Suppression  means  absence  of  the  secretion. 
Tlie  causes  of  retention  are — 

1.  Impacted  calculus  or  foreign  body. 

2.  Alterations  in  the  urethral  walls,  either  permanent^  as  stric- 
ture and  enlarged  prostate,  ov  temporary^  as  congestion  and  spasm. 

3.  Pressure  from  without  the  urethra,  as  in  case  of  certain 
tumors. 

4.  Atony  or  paralysis  of  the  bladder. 

In  retention  due  to  stricture,  the  acute  condition  is  generally 
brought  about  by  an  added  spasm  or  congestion  due  to  excesses 
or  exposure. 

After  operations  or  injury,  spasmodic  retention  is  especially 
liable  to  occur. 

Give  the  symptoms  and  signs  of  retention. 

If  the  condition  comes  on  slowly,  the  bladder  may  become 
enormously  distended,  with  few  local  or  constitutional  signs  other 
than  those  connected  with  urethral  obstruction.  Finally  the 
urine  dribbles  away  as  fast  as  secreted,  the  bladder  still  remain- 
ing full.  This  constitutes  the  condition  known  as  retention  with 
overflow,  and  is  diagnosed  by  outlining  the  full  bladder  by  means 
of  abdominal  percussion,  and  by  passing  a  catheter. 


AFFECTIONS    OF    THE    BLADDER 


231 


Fig.  56. 


In  sudden  and  complete  retention  there  is  intense  local  pain,  with 
rapid  development  of  constitutional  symptoms  of  a  typhoid  type. 

The  bladder,  unless  greatly  stiffened  and  altered  by  previous 
inflammation,  rises  out  of  the  pelvis,  and  can  be  readily  detected 
by  abdominal  examination. 

What  are  the  consequences  of  retention  ? 

Atony,  cystitis,  nexjhritis,  rupture  of  either  the 
bladder,  or  of  the  urethra  behind  a  point  of  obstruc- 
tion, or  retention  with  overflow. 

Give  the  treatment  of  retention  of  nrine. 

If  the  symptoms  are  urgent,  immediate  catheteri- 
zation. 

Betentio^i  due  to  spasmodic  and  congestive  strictures. 

Spasm  and  congestion  are  rarely  suflQcient  in 
themselves  to  cause  retention  ;  they  are  usually  as- 
sociated with  slight  stricture  or  enlargement  of 
prostate,  and  are  brought  on  by  exposure,  debauch, 
or  operation. 

Treatment.  Hot  bath,  and  full  dose  of  tr.  opii 
(TUxxx)  by  the  rectum.  If  there  is  no  spontaneous 
relief,  pass  a  catheter.  Open  the  bowels,  and  keep 
the  urine  unirritating. 

Fig.  57. 


Prostatic  catheter. 


Betention  due  to  organic  stricture.   Attempt  to  pass 

a  soft  catheter  or  filiform,  failing,  give  opium  per 

rectum,  and  hot  bath.     If  the  urine  is  still  not       ^^^^'^''^ 
.  elbowed  ca- 

passed,  anaesthetize  and  again  attempt  to  pass  an     theter. 


232  ESSENTIALS    OF    SURGERY. 

instrument ;  if  unsuccessful,  either  incise,  or  make  a  suprapubic 
aspiration  or  puncture. 

detention  due  to  hypertrophy  of  prostate.  Usually  due  to  con- 
gestion (congestive  stricture),  it  is  induced  by  debauch,  etc. 
Try  the  elbowed  catheter,  the  flexible  catheter  with  stylet,  which 
is  somewhat  withdrawn  when  the  beak  impinges  on  the  prostate, 
the  silver  prostatic  catheter.  If  passed  with  much  difficulty, 
leave  in.  If  bladder  very  full,  draw  off  only  a  part  of  the  urine 
(to  avoid  syncope  and  hemorrhage).  Catheterization  failing, 
do  not  try  to  relax,  but  immediately  puncture,  or  aspirate  above 
the  pubes. 

Betention  due  to  atony  and  paralysis  of  the  bladder  (usually  re- 
tention with  overflow).     Regular  use  of  soft  catheter. 

Describe  suprapubic  tapping  of  the  bladder. 

Trocar  and  canula,  full-sized,  and  with  a  marked  curve,  thrust 
through  the  abdominal  w^all  just  above  the  pubes  and  into  the 
bladder  beneath  the  peritoneal  reflection.  The  trocar  is  with- 
drawn, and  a  rubber  tube  is  passed  through  the  canula  and  left 
in.  In  three  or  four  days  the  tube  is  withdrawn,  leaving  a  short 
sinus  into  the  bladder,  which  may  be  kept  open  indefinitely. 

When  temporary  relief  is  sought  from  retention,  aspirate  in  the 
same  region.  Tapping  may  also  be  done  through  the  pubes, 
through  the  perineum,  through  the  rectum. 

What  are  the  varieties  of  incontinence  of  urine? 

True  incontinence.  The  urine  dribbles  away  as  fast  as  secreted. 
Due  to  either  enlargement  of  the  middle  lobe  of  the  prostate,  or 
disease  or  injury  involving  the  lumbar  cord. 

Nocturnal  incontinence.  Due  to  an  abnormal  reflex  sensibility. 
Slight  irritation,  such  as  might  be  caused  by  worms  or  phimosis, 
causes  micturition. 

Treatment.  For  nocturnal  incontinence,  lateral  decubitus,  and 
regular  emptying  of  the  bladder  once  or  twice  during  the  night. 
Sponge  baths  night  and  morning,  belladonna  pushed  to  its  physi- 
ological limit. 


AFFECTIONS  OF  THE  BLADDER.      233 


Stone  in  the  Bladder. 

What  are  the  common  varieties  of  calculus  ? 

Uric  acid.  Oxalate  of  lime.  Phosphatic  salts.  Among  the  less 
common  varieties  are  the  stones  made  up  of  urates,  cystin, 
xanthin.  Calculi  are  formed  of  concentric  laminae,  frequently 
made  up  of  diflferent  materials  (alternating  calculi).  They  may 
be  single  or  multiple,  free  or  encysted,  only  one  surface,  in  the 
latter  case,  being  subject  to  deposit. 

How  may  you  infer  the  nature  of  a  stone  ? 
By  an  examination  of  the  urinary  sediment. 

How  may  stone  terminate  ? 

In  cystitis,  pyelitis,  nephritis. 

Give  the  symptoms  of  stone  in  the  bladder. 

Pain.  Chronic,  aggravated  by  motion  and  jarring,  felt  across 
the  loins  and  down  the  thighs  ;  also  anacute  pain,  referred  to  the 
end  of  the  penis,  and  most  intense  towards  the  termination  of 
micturition  (the  stone  falls  on  the  sensitive  trigone  and  the 
bladder  walls  contract  upon  it). 

Increased  frequency  of  micturition  during  the  day,  or  while  the 
patient  is  moving  about. 

Hmmaturia.     Slight,  following  micturition. 

Sudden  stopjpage  cf  the  stream  while  micturating.  Cystitis. 
Piles  in  adults.  Elongated  prepuce  in  boys  (from  pulling). 
Prolapse  of  rectum  in  children. 

How  do  you  diagnose  cystic  calculus  ? 

Pass  into  the  bladder  a  solid  or  hollow  sound  with  a  sharply 
curved  bulbous  beak.  Insert  a  finger  into  the  rectum.  By 
manipulating  the  instrument,  and  turning  it  towards  all  portions 
of  the  bladder,  the  stone  may  be  struck.  The  click  of  the  sound 
against  the  calculus  should  be  both  heard  and  felt. 

Under  what  circumstances  may  careful  sounding  fail  to  detect 
stone  ? 
When  the  stone  is  encysted,  or  when  it  is  coated  with  blood 
and  mucus.     If  symptoms  point  to  stone,  sound  repeatedly. 


234 


ESSENTIALS    OF    SURGERY. 


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AFFECTIONS    OF    THE    BLADDER.  235 

How  may  vesical  calculi  be  treated  ? 

By  LitJiolysis  or  solvent  treatment,  practically  useless  in  treat- 
ing bladder  stones,  Lithotrity,  or  crushing  the  stone  in  the 
bladder.  Litholapaxy,  or  crushing  and  washing  out  at  one 
sitting.  Lithotomy,  or  cutting  into  the  bladder  and  removing 
the  stone. 

What  circumstances  guide  you  in  the  choice  of  operation  ? 

Litholapaxy,  in  adults  as  a  rule. 
Lithotomy  is  indicated. 

1.  In  children,  because  the  urethra  is  small,  the  bladder  lies 
high,  and  lithotomy  has  given  the  best  statistics. 

2.  For  large  hard  stones,  an  oxalate  stone  with  maximum 
diameter  greater  than  one  inch  would  indicate  the  cutting 
operation. 

3.  In  case  of  marked  urethral  stricture. 

4.  In  aggravated  cystitis  or  saccidation  of  bladder.  The  incision, 
by  providing  drainage,  would  greatly  amehorate  the  bladder 
disease. 

5.  In  irritable  urethra,  with  tendency  to  urethral  fever. 

Mention  some  sequelae  of  litholapaxy. 

Eigors  and  fever,  retention  of  urine,  cystitis  or  prostatitis, 
hemorrhage,  suppression  of  urine,  phlebitis,  and  pyaemia.  If 
death  occurs,  it  is  mostly  due  to  the  chronic  kidney  trouble. 

Describe  lithotomy. 

May  be  Perineal.  (1.  Lateral.  2.  Median.  3.  Bilateral.) 
Becto-vesical.     Suprapubic. 

Usual  operation.  Lateral  perineal.  Prepare  the  patient  by 
rest  in  bed,  a  laxative  the  night  before,  an  injection  the  morn- 
ing of  operation.  Anaesthetize,  draw  the  urine,  and  inject  six 
ounces  of  warm  water.  Pass  into  the  bladder  a  full-sized 
grooved  staff  and  strike  the  stone.  If  it  is  not  found,  withdraw 
the  staff  and  pass  a  sound.  Faihng  to  strike  it  with  this,  the 
operation  should  be  postponed.  If  the  stone  is  found,  place  the 
patient  in  lithotomy  position,  the  soles  of  the  feet  being  grasped 
in  the  palms  of  the  hands,  and  secured  by  shackles  or  band- 
ages in  this  position  ;  bring  the  nates  down  over  the  end  of  the 


236  ESSENTIALS    OF    SURGERY. 

table,  let  an  assistant  hold  the  staff  directly  in  the  middle 
line  hooked  under  the  pubes,  while  the  operator,  seated  facing 
the  buttocks,  passes  the  finger  of  his  left  hand  into  the  rectum, 
and,  with  the  knife  in  his  right  hand,  makes  an  incision  midway 
between  the  scrotum  and  anus,  and  just  to  the  left  of  the  mid- 
dle line,  doAvnward  and  outward  to  below  the  anus  and  some- 
what nearer  the  tuberosity  of  the  ischium  than  to  this  opening. 
The  incision  divides  skin,  superficial  fascia,  external  hemor- 
rhoidal and  superficial  perineal  vessels,  and  tbe  correspond- 
ing nerves.  Deepen  the  wound,  cutting  transversus  peronei 
muscle  and  artery,  the  lower  border  of  the  triangular  liga- 
ment, and,  possibly,  some  fibres  of  the  accelerator  urinse. 
Search  with  the  disinfected  finger  of  the  left  hand  for  the  staff", 
place  the  point  of  the  knife  in  the  groove,  dividing  the  compres- 
sor urethrse  and  membranous  portion  of  the  urethra.  Turn 
the  blade  somewhat  toward  the  patient's  left  (the  longest  dia- 
meter of  the  prostate),  and  push  it  through  the  levator  pros- 
tatae,  and  the  gland  itself,  till  it  enters  the  bladder.  Withdraw 
the  knife,  and  twist  the  finger  along  the  concave  surface  of  the 
staff"  into  the  bladder.  When  the  stone  is  touched  and  the  staff" 
taken  out,  pass  the  forceps  along  the  -finger ;  on  withdrawing 
the  latter,  there  will  be  a  rush  of  water,  which  commonly  car- 
ries the  stone  into  the  grasp  of  the  instrument.  See  that  the 
stone  is  grasped  with  its  smallest  diameter  presenting,  and 
exert  traction  in  the  axis  of  the  pelvis.  Encysted  calculi  must 
be  removed  by  the  finger  and  a  scoop. 

Apxjly  no  dressing ;  simply  dust  with  iodoform.  Urine  comes 
through  the  lithotomy  wound  for  two  days,  then  from  the 
urethra,  owing  to  swehing  ;  as  inflammation  subsides  it  again 
flows  from  the  wound.  Put  the  patient  in  bed,  on  his  back,  and 
with  a  rubber  bed-pan  to  receive  the  urine. 

What  accidents  may  occur  in  lateral  lithotomy  ? 

Hemorrhage^  from  a  wounded  artery,  or  from  the  prostatic 
plexus. 

Treatment.  Tie  the  bleeding  point.  If  that  cannot  be  accom- 
plished, hsemostatic  forceps,  or  acupressure.  Venous  hemor- 
rhage may  take  place  some  hours  after  the  operation,  the  blood 


AFFECTIONS    OF    THE    BLADDER.  237 

flowing  into  the  bladder  ;  in  which  case  wash  out  all  coagula,  and 
check  the  hemorrhage  by  a  petticoated  tube  packed  with  lint. 

Other  less  common  accidents  are,  wound  of  rectum^  wound  of 
bladder,  and  tearing  the  urethra  across,  the  latter  complication 
especially  liable  to  occur  in  children.  If  the  urethra  is  pushed 
off  the  staff,  the  operation  must  be  abandoned. 

Mention  some  causes  of  death  after  lithotomy. 

Infiltration  of  urine,  from  opening  of  recto-vesical  fascia  ;  dif- 
fuse inflanwiation,  from  bruising  ;  hemorrhage,  i:)yoemia,  peritoni- 
tis, shock,  cystitis,  suppression  of  urine. 

Describe  median  lithotomy. 

Pass  a  grooved  staff  as  before.  Eeel  the  apex  of  the  prostate 
with  the  finger  in  the  rectum.  Make  an  incision  in  the  median 
line  of  the  perineum,  beginning  ^  inch  from  the  anus,  and  pass 
the  point  of  the  knife  into  the  groove  of  the  staff,  nicking  the 
apex  of  the  prostate  and  dividing  the  membranous  portion  of 
the  urethra. 

What  are  the  indications  for  median  lithotomy  ? 

S7nall  stones,  foreign  bodies,  exploratory  incisions. 

Describe  suprapubic  lithotomy. 

This  operation  consists  in  opening  the  anterior  wall  of  the 
bladder,  below  the  peritoneal  reflection. 

Position.  On  the  back,  with  the  buttocks  elevated.  Inflate 
the  rectum  moderately,  by  means  of  a  rubber  bag  distended  with 
air  or  water.  Draw  the  urine,  and  inject  four  to  six  ounces  of 
boracic  acid  solution  into  the  bladder.  Incision  through  the 
linea  alba,  immediately  above  the  symphysis.  Tear  through  the 
fibrous  and  fatty  tissues  till  the  wall  of  the  bladder  is  exposed. 
Draw  the  peritoneal  reflection  upward.  Incise  below  its  attach- 
ment. Enlarge,  if  necessary,  by  tearing,  and  extract  the  stone. 
The  patient  maintains  the  lateral  decubitus,  changing  from  one 
side  to  the  other.  This  drains  the  bladder.  A  rubber  air-cushion 
is  arranged  to  receive  the  urine. 

What  are  the  indications  for  suprapubic  lithotomy  ? 

Large,  hard  stones,  of  a  greater  diameter  than  one-and-a-half 
inches. 


238  ESSENTIALS    OF    SURGERY. 

This  method  of  cystotomy  is  also  advised  in  cases  of  tumor  of 
the  bladder.  Many  surgeons  consider  this  operation  as  prefera- 
ble in  nearly  all  cases  where  the  bladder  has  to  be  opened. 

What  are  the  symptoms  of  calculus  impacted  in  the  urethra  ? 

Sudden  stoppage  of  the  stream,  great  pain,  a  drop  or  two  of 
blood,  and  retention  of  urine. 

Treatment.  If  possible,  work  it  forward  along  the  urethra, 
grasp  and  extract  with  urethral  forceps.  Stretch  the  skin  over 
it  and  extract  by  a  small  incision,  letting  the  wound  granulate. 
If  at  the  neck  of  the  bladder,  do  a  median  lithotomy. 

Hydrocele. 

Name  the  varieties  of  hydrocele. 

1.  Vaginal  hydrocele.  This  is  the  common  variety ;  the 
serous  effusion  is  in  the  tunica  vaginalis  testis.  Hydrocele  im- 
plies this  form. 

2.  Congenital  hydrocele.  Arises  from  an  imperfect  closure  of 
the  communication  between  the  peritoneal  cavity  and  the  tunica 
vaginalis. 

3.  Encysted  hydrocele  of  the  testis  or  epididymis.  Really  cystic 
growths  from  these  structures.  The  fluid  is  often  opalescent 
and  contains  spermatozoa. 

4.  Encysted  hydrocele  of  the  cord.  A  serous  eff'usion  into  an 
unobliterated  portion  of  the  funicular  part  of  the  tunica  vagi- 
nalis. 

What  are  the  symptoms  of  hydrocele  ? 

A  smooth,  tense,  elastic,  fluctuating  swelling  in  the  scrotum  ; 
of  'pyriform  shape,  and  translucent.  The  testicle  lies  behind  it  and 
near  its  lower  part. 

In  congenital  hydrocele  the  effusion  can  be  slowly  pressed 
back  into  the  peritoneal  cavity,  to  reappear  when  pressure  is 
removed. 

Give  the  treatment  of  hydrocele. 

Palliative.  Discutient  remedies  (especially  in  the  congenital 
form),  such  as  muriate  of  ammonia  ^ss  to  aq.  Jj,  or  weak  solu- 


HYDROCELE.  239 

tions  of  iodine.     Tapping  and  draining  off  the  fluid  by  trocar 
and  canula. 

Badical.  Tapping  and  injection  of  iodine.  Incision,  drain- 
age, and  antiseptic  dressing.     Excision  of  sac. 

Describe  tapping  a  hydrocele. 

See  that  the  trocar  and  canula  are  dean,  and  movable  on  each 
other.  Determine  the  position  of  the  testicle.  Grasp  the 
enlargement  with  the  left  hand,  making  its  anterior  portion 
tense.  Thrust  the  trocar  directly  backward,  turning  it  upward 
as  soon  as  it  has  entered  the  sac.  Evacuate  the  fluid,  withdraw 
the  canula,  and  close  the  wound  with  iodoform  collodion. 

If  the  hydrocele  is  to  be  radically  cured,  inject,  after  draining 
the  fluid,  tr.  iodin.  ^ij,  and  manipulate  the  scrotum  so  that  the 
injection  may  come  in  contact  with  every  portion  of  the  sac 
walls.  Withdraw  the  canula,  and  close  the  wound  as  before. 
Acute  inflammation  shortly  follows,  and  the  swelling  may  even 
exceed  its  original  extent.  It  shortly  subsides,  obliterating  the 
cavity  by  inflammatory  adhesions. 


Hsematocele. 

What  is  hsematocele  ? 

An  effusion  of  blood  into  the  tunica  vaginalis  testis.     Strictly, 
the  term  includes  effusion  in  connection  with  either  testis  or 


What  are  the  causes  of  hsematocele? 

Traumatism,  or  spontaneous  rupture  of  diseased  bloodvessels. 

How  do  you  diagnose  hsematocele  ? 

A  smooth,  tense,  semifluctuating,  pyriform  swelling  appears 
rather  suddenly.  It  is  opaque  by  transmitted  light,  gives  to  the 
exploring  needle  disorganized  blood,  and  is  often  accomj)anied 
by  considerable  ecchymosis  of  the  scrotum. 

Give  the  treatment  of  hsematocele. 

If  recent,  rest  in  bed,  elevation,  and  application  of  cold.  If 
this  fails,  incise  and  evacuate. 


240  ESSENTIALS    OF    SURGEEY. 

Varicocele. 

What  is  varicocele  ? 

A  varicose  condition  of  the  pampiniform  plexus. 

Why  is  varicocele  commonly  found  on  the  left  side  ? 

1.  The  left  spermatic  vein  is  longer.  2.  It  opens  into  the 
7'enal  vein  at  riylit  angles  to  the  blood-current.  3.  It  is  crossed 
by  the  sigmoid  flexure,  and  hence  subject  to  pressure  from  faecal 
accumulations. 

What  are  the  symptoms  of  varicocele  ? 

Dragging  pain  and  discomfort,  reheved  by  recumbency. 
Considerable  mental  depression.  On  examination  there  is  found 
a  soft,  knotted,  irregular,  opaque,  pyriform  tumor,  feeling  like  a 
bunch  of  earth-worms  ;  it  gives  an'  impulse  on  coughing,  and 
gradually  disappears  on  lying  down. 

Give  the  treatment  of  varicocele. 

General  hygiene,  regular  exercise,  cold  sponging,  and  local 
douches.  The  bowels  should  be  regulated,  and  a  suspensory 
bandage  worn,  with  a  ring  through  which  a  portion  of  the  scro- 
tum can  be  drawn. 

Badical.    Subcutaneous  ligation  or  acupressure.    Excision. 

Sarcocele. 

Name  the  surgical  affections  of  the  testicle. 

Epididymitis  and  orchitis,  acute  or  chronic.  Syphilitic,  tuher- 
cidar,  cystic,  or  malignant  disease.  All  these  enlargements  may 
be  accompanied  by  hydrocele. 

What  is  sarcocele  ? 

A  term  applied  to  all  solid  enlargements  of  the  testes,  hence 
we  have  simple,  tuhercular,  malignant  sarcocele,  etc. 

(For  acute  epididymitis  see  pages  213,  216.  Acute  orchitis  has 
the  same  symptomatology  and  treatment. ) 

Describe  simple  sarcocele. 

Due  to  simple  chronic  orchitis.     It  is  simply  an  overgrowth 


SARCOCELE.  241 

of  the  connective  tissue,  following  an  acute  attack  of  inflamma- 
tion ;  forming  a  smooth,  hard,  non-sensitive  enlargement.    Tes- 
ticular sensation  may  ultimately  disappear.      This  indicates 
atrophy  of  the  secreting  tissues. 
Treatment.     Strap. 

Describe  syphilitic  sarcocele. 

Pathology.  Either  a  diffused  or  localized  induration  (gumma). 
The  testicle,  at  first  smooth  and  globular,  becomes  nodular.,  of 
stony  hardness^  and  non-sensitive.  The  tumor  preserves  its  gene- 
ral ovoid  outline. 

Treatment.     Strapping  and  constitutional  medication. 

Describe  tubercular  disease  of  the  testicle. 

The  diagnostic  points  of  tubercular  sarcocele  are  :  It  occurs  in 
the  young  adult,  whose  family  history  is  frequently  strumous, 
it  is  indolent  and  slow  in  development,  the  epididymis  is  first 
attacked,  there  is  rarely  hydrocele,  the  vas  deferens  is  thick- 
ened, and  the  induration  is  prone  to  break  down. 

Treatment.  Constitutional.  Total  ablation  of  diseased  area. 
Castration  if  necessary. 

Describe  fibro-cystic  disease  of  the  testes. 

Occurs  in  old  men,  and  is  a  gradual,  painless,  unilateral  en- 
largement, attended  with  absence  of  testicular  sensation,  and 
presenting  no  history  of  previous  injury  or  inflammation^ 

Treatment.     Castration. 

Describe  malignant  disease  of  the  testicle. 

Sarcoma,  most  common,  small  round-celled.  Carcinoma,  usu- 
ally encephaloid.  The  diagnosis  from  fibro-cystic  disease  is 
made  by  the  exceeding  rapidity  of  the  growth,  which  involves 
the  skin  and  ulcerates.  All  the  signs  of  malignant  disease  are 
present. 

16 


242  ESSENTIALS    OF    SURGERY. 


DISEASES  OF  VEINS. 

What  is  thrombosis  ? 

A  clot  formed  in  a  vessel  during  life. 

What  are  the.  causes  of  venous  thrombosis? 

1.  Inflammation,  injury,  or  degeneration  of  the  walls  of  a 
vein. 

2.  Alteration  in  the  blood,  blood  stasis,  or  exhaustion. 

What  becomes  of  a  thrombus  ? 

It  may  organize,  it  may  calcify,  forming  phleboliths,  or  it 
may  undergo  red  or  yellow  (septic)  softening. 

What  are  the  symptoms  of  thrombosis  ? 

CEdema,  and  the  detection  of  a  tender,  knotted,  cord-like 
swelling  in  the  course  of  a  vein.     There  is  pain  on  motion. 

How  do  you  treat  thrombosis  ? 

Rest  and  elevation.  Mercury  and  belladonna  ointment  thickly 
applied,  hot  fomentations.  Clear  the  bowels  by  a  saline  cathartic, 
give  a  simple  but  nourishing  diet,  and  administer  iron  and 
quinine.  Subsequently  apply  a  pressure  bandage,  and  use  fric- 
tion and  massage. 

What  are  the  causes  of  phlebitis  ? 

Traumatism,  thrombosis,  gout,  micro-organisms. 

What  are  the  symptoms  of  phlebitis  ? 

A  dusky  red  line  in  the  course  of  the  vein,  and  the  symptoms 
of  thrombosis.     Treatment  as  for  thrombosis. 

Describe  suppurative  phlebitis. 

Cause.     Septic  micro-organisms. 

Symptoms.  As  for  phlebitis  and  thrombosis.  Local  inflam- 
matory signs  are  more  marked  ;  there  are  frequently  softening 
and  suppuration  in  the  course  of  the  vein,  and  constitutional 
symptoms  and  metastatic  abscesses  indicate  the  development  of 
pyaemia. 

Prognosis.     Unfavorable. 


DISEASES    OF    VEINS  243 

Treatment.  Local  disinfection  and  opening  of  abscesses  ;  am- 
putation, if  the  diagnosis  can  be  made  sufficiently  early. 

What  is  a  varix  ? 

A  permanent  dilatation  of  a  vein.  The  vein  is  said  to  be 
varicose. 

What  are  the  causes  of  varicose  veins  ? 

Increased  intravenous  pressure  from  mechanical  compression, 
from  violent  muscular  contractions  emptying  the  deep  veins  into 
the  superficial,  from  loTig  standing.  Alteration  in  the  vein 
walls. 

What  are  the  symptoms  of  varix  ? 

Aching  pains,  and  a  sense  of  fulness  after  standing,  together 
with  the  enlargement  evident  to  the  sight  and  touch.  Muscular 
cramps  are  said  to  characterize  deep  varix. 

How  do  you  treat  varicose  veins  ? 

Palliative.  As  much  rest  and  elevation  of  the  part  as  possible, 
the  application  of  a  rubber  bandage  or  an  elastic  stocking,  tonics, 
and  laxatives. 

Badical.    Ligature  and  excision,  or  acupressure. 


241  ESSENTIALS    OF    SURGERY 


ANGIOMA. 

Describe  the  different  varieties  of  angiomata. 

1.  Arterial  varix.  A  dilatation  and  lengthening  of  a  single 
artery. 

2.  Cirsoid  aneurism.  A  tumor  composed  of  a  number  of  di- 
lated and  tortuous  arteries. 

3.  Aneurisnz  by  anastomosis.  A  dilatation  and  lengthening, 
involving  the  arteries,  capillaries,  and  lesser  veins. 

4.  Capillary  noevus.  A  dilatation  and  tortuosity  involving  the 
capillaries. 

5.  Venous  ncevus.  A  tumor  composed  of  a  number  of  inter- 
communicating spaces  lined  with  endothelium,  into  which  the 
arteries  empty,  and  from  which  the  veins  take  their  origin. 

How  do  you  treat  angiomata  ? 

Arterial  varix^  circoid  aneuris7n,  aneurism  hy  anastomosis.  Pro- 
tect. If  rapidly  extending,  excise,  cutting  free  of  the  involved 
area,  and  tying  each  artery  as  it  is  cut.  Ligation  of  the  main 
artery  of  the  part,  or  injection  of  perchloride  of  iron  may  also 
be  tried. 

Ncevus.  Very  large  superficial  nsevi  (port-wine  marks),  and 
those  which  are  neither  increasing  in  size  nor  produce  visible 
deformity,  should  not  be  treated.  Under  other  circumstances 
capillary  ncevi  may  be  removed  by  superficial  cauterization,  or 
incision,  or  escharotics  lightly  applied  ;  venous  ncevi  may  be 
cured  by  incision,  carried  free  of  the  diseased  area  ;  by  ligation, 
the  thread  being  placed  subcutaneously,  or  in  an  incision  made 
through  the  skin  ;  by  electrolysis,  by  coagulating  injections. 


ANEURISM.,  245 

ANEURISM. 

What  is  an  aneurism  ? 

A  blood  tumor  communicating  with  the  interior  of  an  artery. 

Give  the  classification  of  aneurisms. 

1.  Traumatic  (see  p.  74^.  2.  Spontaneous. 

a.  Diffused.  a.  Tubular  or  fusiform. 

h.  Circumscribed.  6.  Sacculated. 

c.  Arterio-venous.  c.   Dissecting. 

The  cirsoid  aneurism  and  aneurism  by  anastomosis  are,  pro- 
perly, varieties  of  spontaneous  aneurism. 

Describe  spontaneous  aneurism. 

Tubular  or  fusiform.  A  circumscribed  dilatation  of  the  whole 
circumference  of  the  artery.     The  sac  consists  of  all  three  coats. 

Sacculated.  The  dilatation  involves  a  portion  of  the  circum- 
ference only.  The  sac  consists  of  the  outer  coat  and  of  con- 
densed areolar  tissue.     May  be  circumscribed  or  diffused. 

Dissecting.  The  internal  and  a  portion  of  the  middle  coat 
have  yielded,  the  blood  forcing  its  way  between  the  layers  of  the 
middle  coat. 

What  are  the  causes  of  spontaneous  aneurism? 

PredAsposing.  Atheroma,  an  embolus,  leading  to  inflamma- 
tory softening. 

Exciting.     Blows,  strains,  or  sudden  violent  exertion. 

How  may  an  aneurism  terminate  ? 

1.  In  spontaneous  cure.     2.  In  death. 

Spontaneous  cure  may  be  effected  by,  1,  gradual  consolidation 
by  deposit  of  laminated  clot ;  2,  arterial  occlusion  above  or  below 
the  sac  by  a  fibrinous  plug,  or  by  the  aneurism  itself;  3,  inflam- 
mation of  the  sac  and  consequent  clotting  of  the  contained 
blood  ;  4,  suppuration  and  gangrene.  Aneurism  may  cause 
death  by  pressure,  by  rupture  and  bleeding,  by  gangrene. 

What  are  the  diagnostic  signs  of  aneurism  ? 

A  tumor  in  the  course  of  an  artery,  diminished  in  size  by 


246  ESSENTIALS    OF    SURGERY. 

pressure  of  the  main  artery  above,  increased  in  size  by  pressure 
upon  the  artery  below.  Characterized  by  thrill,  bruit,  and  ex- 
pansile pulsation.  The  pulse  in  the  artery  below  the  aneurism 
is  delayed  in  time,  and  more  feeble  than  that  of  the  opposite 
side  of  the  body.  There  are  various  pressure  effects,  such  as 
oedema,  bony  erosions,  pain,  muscular  spasm,  etc. 

How  do  you  treat  aneurism  ? 

1.  Medical  treatment.  Absolute  rest.  Yery  restricted  diet. 
Iodide  of  potassium. 

2.  Surgical  treatment.  {!.)  Pressure.  May  be  (^z-reci,  upon  the 
aneurismal  sac,  or  indirect,  upon  the  artery  above  or  below.  It 
may  be  digital,  instrumental^  or  applied  by  an  Esmarch's  band- 
age. It  may  be  so  applied  as  to  merely  slow  the  blood-current 
producing  laminated  clots,  or  may  completely  stop  the  circulation 
(rapid  pressure).  (2.)  Flexion.  Usually  combined  with  pres- 
sure. (3.)  Ligation.  The  thread  may  be  applied  to  the  ar- 
tery, 1,  above  the  aneurism,  and  at  some  distance  from  it 
(Hunter's  operation),  2,  just  above  the  aneurism  (Anel's  opera- 
tion), 3,  both  above  and  below  the  aneurism  (operation  of 
Antyllus,  or  old  operation),  4,  just  below  the  aneurism  (Brasdor's 
operation),  5,  to  one  or  more  of  the  main  branches  below  the 
aneurism  (Wardrop's  operation).  (4.)  Maniimlation.  (5.)  Oal- 
vano-puncture.    {6.)  Injections.     (7.)  Introduction  of  foreign  bodies. 

Describe  the  application  of  digital  pressure  to  the  cure  of  aneu- 
rism. 

This,  if  it  can  be  applied  on  the  proximal  side  of  the  artery  at 
some  distance  from  the  sac,  is  superior  to  other  methods  of  pres- 
sure, since  it  is  less  painful,  it  is  less  liable  to  injure  the  soft 
parts,  it  does  not  obstruct  venous  circulation.  This  method  can 
be  combined  with  flexion  and  instrumental  compression.  Kelays 
of  assistants  are  necessary  for  its  proper  application.  The  pres- 
sure is  made  with  the  thumbs,  the  artery  being  controlled  by  the 
next  assistant  before  the  one  pressing  is  relieved.  A  hand  should 
be  kept  constantly  on  the  sac  to  see  that  pulsation  is  prevented. 

This  method  is  not  applicable  to  very  large  aneurisms  accom- 
panied by  much  cedema  from  venous  obstruction,  or  aneurisms 


ANEURISM.  247 

occurring  in  habitual  drunkards  or  tliose  of  irritable  disposi- 
tion. 

Describe  Hunter's  method  of  ligation. 

The  ligature  is  applied  so  high  above  the  artery  that  a  double 
collateral  circulation  is  established,  one  around  the  thread,  the 
other  around  the  aneurism.  The  cure  is  effected  by  diminish- 
ing the  circulation,  and  favoring  the  deposition  of  laminated  clots 
in  the  aneurismal  sac  ;  these  organize  much  more  readily  than 
the  currant-jelly  clots. 

When  the  hgature  is  applied,  pulsation  can  no  longer  be  felt 
in  the  aneurism  ;  after  awhile  a  slight  pulse  is  again  perceptible  ; 
as  the  sac  becomes  occluded,  this  pulsation  becomes  more  feeble, 
till  it  finally  ceases  permanently.  After  operation,  the  limb 
should  be  swathed  in  cotton,  elevated,  and  kept  warm. 

What  are  the  dangers  of  ligation  ? 

Gangrene,  secondary  hemorrhage,  suppuration  and  sloughing, 
recurrent  pulsations. 

What  are  the  abjections  to  ligation  close  to  the  aneurismal  sac? 

The  artery  is  probably  not  healthy.  The  circulation  is  abso- 
lutely stopped,  hence  there  is  clotting  in  mass.  The  anatomi- 
cal relations  of  the  vessel  are  frequently  altered  by  the  tumor, 
making  the  operation  difficult.  The  aneurismal  sac  is  liable  to 
■injury  during  the  operation. 

How  do  you  treat  traumatic  aneurisms  ? 
Turn  out  the  clots,  and  ligate  above  and  below. 


248  ESSENTIALS    OF    SURGERY. 


DISEASES  OF  THE  LYMPHATICS. 

Describe  lymphangitis. 

Definition.     Inflammation  of  lymphatic  vessels. 

Causes.  Septic  absorption  from  a  wound,  or  simple  trauma- 
tism. 

Symptoms.  Irregularly  placed  erythematous  patches,  and  red 
lines  running  to  the  nearest  lymphatic  glands,  which  are  en- 
larged and  tender.     Chill  followed  by  fever. 

Treatment.  Cleanse  wounds  and  render  aseptic.  Promptly 
evacuate  pus.  Elevate  and  apply  hot  antiseptic  fomentations. 
On  subsidence  of  acute  symptoms,  apply  belladonna  and  mer- 
cury ointment,  together  with  pressure.  Clear  the  bowels,  give 
diaphoretics  and  diuretics. 

Differential  diagnosis.  From  phlebitis,  by  absence  of  knotted, 
corded  feeling,  and  dusky  redness  in  the  course  of  veins ;  by  the 
presence  of  glandular  involvement. 

Describe  lymphadenitis. 

Definition.  Inflammation  of  lymphatic  glands.  May  be  acute 
or  chronic. 

Acute  lymphadenitis  is  usually  secondary  to  inflammation  of 
soft  parts.  The  symptoms  are  those  of  inflammation  or  abscess. 
The  treatment  consists  in  cleansing  the  source  of  trouble,  the 
use  of  hot  applications,  prompt  incision  for  pus,  pressure,  and 
applications  of  mercury  and  belladonna. 

Chronic  lymphadenitis.  Common  in  strumous  children,  arises 
from  slight  irritation  or  without  obvious  cause.  Glands  of  the 
neck  frequently  afiected.  Characterized  by  slow,  painless,  en- 
largements, which  discharge  curdy  pus  on  breaking  down,  and 
leave  indolent,  undermined  ulcers. 

Treatm^ent.  Counter-irritation  by  iodine  till  signs  of  softening, 
then  incise,  curette,  and  dress  antiseptically.  Nourishing  diet, 
fresh  air,  cod-liver  oil,  iodide  of  iron. 


EFFECTS    OF    COLD.  249 


EFFECTS  OF  COLD. 

How  may  death  occur  from  cold  ? 

From  cerebral  ancemia,  caused  by  sudden  and  progressive 
chilling.  From  cerebral  congestion,  due  to  slow  and  continuous 
chilling.     From  embolism,  due  to  sudden  reheating. 

Describe  the  local  effects  of  cold. 

Pernio  or  chilblain.  Caused  by  sudden  alterations  in  tempera- 
ture. Characterized  by  swelling,  congestion,  vesication,  and 
intense  itching  and  burning.  Frequent  recurrence  from  slight 
causes. 

Treatment.  Restore  circulation  gradually  by  friction  with 
snow,  by  the  use  of  cold  water.  Apply  a  one  per  cent,  solution 
of  nitrate  of  silver,  and  wrap  in  raw  cotton. 

Frost-bite.  Characterized  by  actual  congelation  of  the  part, 
which  is  brittle  and  of  a  tallowy  whiteness  ;  subsequently  in- 
flammation of  a  high  grade  appears,  and  may  be  followed  by 
gangrene. 

Treatment.  Moderate  the  severity  of  reaction  by  rubbing  with 
snow,  continued  cold  irrigation,  massage.  If  mortification  ap- 
pears, continue  the  use  of  cold  as  long  as  this  process  is  inclined 
to  spread.    Amputate  when  the  line  of  separation  is  formed. 


250  ESSENTIALS    OF    SURGERY. 


FOREIGN  BODY  IN  THE  AIR-PASSAGES. 

At  what  portions  of  the  air-passages  do  foreign  bodies  become 
impacted  ? 

Commonly  in  the  larynx,  or  the  right  bronchus. 

What  are  the  symptoms  of  foreign  body  in  the  air-passages? 

If  impacted  in  the  larynx.  Asphyxia  from  spasm  and  obstruc- 
tion ;  this  may  cause  immediate  death,  or,  the  first  spasm  passing 
away,  may  be  succeeded  by  an  exhausting  cough,  a  blood-stained 
mucous  expectoration,  and  recurring  spasmodic  attacks. 

If  loose  in  the  trachea.  Recurring  and  violent  attacks  of  spas- 
modic asphyxia  from  impact  of  the  body  against  the  rima 
glottidis,  free  secretion  of  a  frothy  mucus  from  the  air-passages. 

If  impacted  in  a  bronchus.  Pain  and  whistling  rales  at  the 
seat  of  lodgment,  absence  of  respiratory  sounds  in  the  lung, 
abscess. 

Treatment.  If  dyspncea  urgent,  instant  tracheotomy.  If  the 
foreign  body  is  lodged  in  the  larynx,  an  effort  should  be  made  to 
remove  it  by  laryngeal  forceps  ;  failing  in  this  perform  laryn- 
gotomy  and  thyrotomy  if  necessary ;  let  the  patient  wear  a 
tracheal  tube  for  twenty-four  hours.  If  the  foreign  body  is  loose 
in  the  trachea,  immediately  traeheotomize,  draw  the  wound  open, 
invert  the  patient,  and  instruct  him  to  cough.  If  the  foreign 
body  is  lodged  in  a  bronchus,  endeavor  to  extract  by  means  of 
wire  or  an  instrument,  passed  through  a  tracheal  opening. 

What  is  bronchotomy  ? 

Laryngotomy  and  tracheotomy,  with  their  modifications.  1. 
Thyrotomy,  opening  through  the  thyroid  cartilages.  2.  Laryn- 
gotomy, opening  through  the  crico-thyroid  membrane.  3. 
Laryngo-tracheotomy,  opening  through  crico-thyroid  mem- 
brane, cricoid  cartilage,  and  upper  rings  of  the  trachea.  4. 
Tracheotomy,  opening  through  the  rings  of  the  trachea. 

Under  what  circumstances  is  bronchotomy  required  ? 

Acute  laryngitis,  or  oedema  glottidis.  Spasm.  Emphysema. 
Foreign  bodies  in  the  air-passages,  or  gullet.  Croup.  Diph- 
theria.   Polypi. 


FOREIGN    BODY    IN    THE    AIR- PASS  AGES .       251 

What  structures'lie  in  the  middle  line  of  the  neck  ? 

Thyro-hj'oid  membrane,  thyroid  cartilage,  crico-thyroid  mem- 
brane and  arteries,  cricoid  cartilage,  two  or  three  tracheal  rings, 
isthmus  of  the  thyroid,  trachea. 

Describe  laryngotomy. 

Longitudinal  skin  incision,  an  inch-aud-a-half  long,  is  made 
over  the  thyroid  cartilage,  thyro-cricoid  membrane,  and  cricoid 
cartilage  ;  the  crico-thyroid  membrane  is  opened  by  a  transverse 
cut. 

Describe  tracheotomy. 

In  the  high  operation  the  opening  is  made  above  the  isthmus 
of  the  thyroid  ;  in  the  low  operation  it  is  made  below. 

Incision  for  high  operation,  two  and  a  half  inches  long,  begin- 
ning at  the  upper  border  of  the  cricoid  cartilage.  Divide  skin, 
superficial  fascia,  sterno-hyoid  and  sterno-thyroid  inter-muscu- 
lar fascia,  and  loose  cellular  tissue.  Avoid  anterior  jugular  veins 
and  their  communicating  branch,  inferior  thyroid  vein,  and  mid- 
dle thyroid  artery,  if  present.  Draw  the  trachea  forward  with 
a  tenaculum,  incise,  cutting  from  below  upward,  and  pass  in  the 
tracheal  tube.  Check  all  bleeding  before  opening  the  larynx, 
excex^t  when  death  from  asphyxia  is  imminent,  or  when  the 
bleeding  is  due  to  intense  venous  engorgement. 

After-treatment  should  be  conducted  in  a  warm,  moist  atmo- 
sphere ;  the  opening  of  the  tracheal  tube  should  be  protected  by 
moist  gauze,  and  a  physician  or  nurse  should  be  constantly 
present  to  clean  the  inner  tube  when  it  becomes  filled.  When 
the  breathing  becomes  hissing,  and  the  epigastrium  and  intercos- 
tal spaces  are  sucked  in  during  inspiration,  the  tube  is  danger- 
ously clogged.  Bronchitis,  pneumonia,  or  the  disease  which 
necessitates  the  operation,  are  the  common  causes  of  death  after 
this  operation. 


Affections  of  the  (Esophagus. 

Where  are  the  narrowest  portions  of  the  oesophagus? 

At  its  commencement  (the  low(!r  Ijorder  of  the  cricoid  carti- 
lage), and  as  it  passes  through  the  diaphragm. 


252  ESSENTIALS    OF    SURGERY. 

What  are  the  symptoms  of  foreign  body  in  the  oesophagus  ? 

Pain,  difficulty  in  swallowing,  and  frequently,  asphyxia  from 
spasm  or  direct  pressure. 

How  do  you  treat  foreign  body  in  the  oesophagus  ? 

If  suffocation  threatens,  tracheotomize  at  once.  Under  other 
circumstances,  endeavor  to  extract  by  forceps,  or  by  the  swivel 
or  horsehair  probang.  If  the  body  is  of  such  a  nature  that 
it  can  be  digested,  or  passed  by  the  bowel,  push  it  into  the 
stomach.  If  the  body  is  irregular  and  tightly  lodged,  perform 
oisophagotomy. 

Describe  stricture  of  the  oesophagus. 

1.  Spasmodic.  Occurs  in  young  hysterical  women.  Gives 
trouble  only  at  times.  Under  ether,  a  bougie  is  passed  without 
difficulty. 

2.  Fibrous.  Due  to  contractions  following  traumatism  or 
syphilis. 

3.  Malignant.  Generally  epitheliomatous.  Occurs  opposite 
cricoid  cartilage,  tracheal  bifurcation,  or  at  cardiac  end  of  stom- 
ach. 

Symptoms  of  fibrous  or  malignant  stricture  are,  increasing  dif- 
ficulty in  swallowing,  first  solids  then  liquids  giving  trouble.  A 
feeling  of  obstruction  referred  to  the  top  of  the  sternum,  regurgi- 
tation of  swallowed  food,  progressive  wasting.  Finally  the  di- 
agnosis is  made  by  passage  of  bougies  (after  excluding  aneurism, 
which  has  been  burst  by  this  procedure). 

Treatment.  Dilatation  or  internal  oesophagotomy  for  fi.brous 
strictures.  (Esophagotomy  (establishment  of  a  fistulous  open- 
ing into  the  oesophagus),  or  gastrostomy  for  malignant  strictures. 


SURGICAL    AFFECTIONS    OF    THE    BREAST.      253 


SURGICAL  AFFECTIONS  QF  THE  BREAST. 

In  what  situation  may  abscesses  of  the  breast  occur  ? 

8upra-ma7nmary,  superficial  to  the  gland.  Tntra-mammary, 
within  the  gland.     Post-mammary^  behind  the  gland. 

Give  the  treatment  of  mammary  abscess. 

Early  and  free  incision  in  a  direction  radiating  from  the  nip- 
ple, drainage,  and  pressure  by  means  of  bandages  or  concentric 
strapping. 

What  is  Paget's  disease  of  the  nipple? 

An  inflammatory  condition  of  the  nipple  and  areola  which 
frequently  precedes  the  development  of  cancer. 

What  tumors  are  most  frequently  found  in  the  breast? 

Scirrhus,  fibroma,  sarcoma. 

Give  the  differential  diagnosis  between  scirrhus  and  non-malig- 
nant breast  tumors. 

Scirrhus.  Non-malignant  tumors. 

Occurs  after  the  fortieth  year.  Occurs  before  the  fortieth  year. 

Very  hard,  nodulated,  shortly  he-  Nodulated,  moderately  hard,  elas- 
comes  fixed.  tic,  movable. 

Skin  infiltrated  and  adherent.  Skin  free  and  movable. 

Nipple  retracted,  superficial  veins      None  of  these  signs  present. 
dilated,  lancinating  pain. 

Lymphatic     involvement,     rapid 
growth,  quick  recurrence,  cachexia. 


254  ESSENTIALS    OF    SURGERY, 


qLUB-FOOT. 

Describe  the  common  forms  of  club-foot. 

1.  Talipes  varus.  The  sole  of  the  foot  looks  inward.  This  is 
the  commonest  congenital  form  (usually  equino-varus) ;  when 
it  affects  both  feet  it  is  frequently  associated  with  spina  bifida. 
Cause.  Contraction  of  tibiahs  anticus  and  posticus,  muscles  of 
the  calf,  and  the  plantar  fascia.  Treat7nent.  Division  of  all  re- 
sisting tissues. 

2.  Talipes  equinus.  The  heel  is  raised.  Cause.  Contraction 
of  gastrocnemius  and  soleus,  or  paralysis  of  the  opposing  mus- 
cles.    Treatment.   Division  of  tendo  Achillis. 

3.  Talipes  valgus.  The  foot  is  everted.  Caused  by  long-con- 
tinued standing,  or  anything  tending  to  obliterate  the  plantar 
arch;  the  ]3eronei  muscles  subsequently  contract.  Treatment. 
Friction,  support  to  the  arch  of  the  foot,  and  section  of  peronei 
tendons,  if  necessary. 

4.  Talipes  calcaneus.  The  toes  are  raised  by  the  extensors. 
Causes.  Contraction  of  the  anterior  muscles,  or  paralysis  of  those 
of  the  calf.  Treatment.  Section  of  the  tibialis  anticus,  extensor 
longus  poUicis,  extensor  longus  digitorum,  peroneus  tertius. 

There  may  be  a  combination  of  distortions,  constituting  equmo- 
varus,  calcaneo-varuSj  etc. 


HARE-LIP    AND    CLEFT    PALATE 


255 


HARE-LIP  AND  CLEFT  PALATE. 


Fig.  58. 


What  is  hare-lip  ? 

A  congenital  deformity,  characterized  by  a  fissure  or  fissures  on 
the  upper  lip,  due  to  arrested  development.     Hare-lip  is  single 
when  one  side  is  involved,  double 
when  it  appears  on  both  sides.     It 
is  frequently  associated  with  cleft 
palate. 

The  treatment  consists  in  closing 
the  fissure,  by  freshening  the  edges 
and  bringing  them  together  with 
hare-lip  pins,  or  by  performing  a 
plastic  operation,  sacrificing  none  of 
the  tissues. 

What  is  cleft  palate  ? 

A  congenital  cleft  in  the  median 
line  of  the  palate  ;  it  may  be  con- 
fined to  the  uvula,  the  soft  palate, 
or  involve  the  entire  roof  of  the 
mouth. 

Staphylorraxjliy  indicates  the  operation  for  the  closure  by 
suture  of  the  soft  palate.  The  method  of  closing  the  fissure  by 
a  transparent  flap  from  the  pharynx  is  termed  staphyloplasty. 
The  flap  operation  for  the  closure  of  clefts  in  the  hard  palate  is 
termed  uranoplasty. 


Operation  for  hare-lip. 


256  ESSENTIALS    OF    SURGERY. 

DISEASES  OF  BURS^  AND  TENDONS. 

Bursitis. 

Describe  bursitis. 

Bursitis  is  characterized  by  pain,  fever,  and  tlie  rapid  develop- 
ment of  a  fluctuating  swelling.  The  bursa  patellae  is  commonly 
involved,  constituting,  in  the  chronic  form,  "  housemaid's  knee." 
This  swelhng  is  diagnosed  from  intra-articular  effusions  by  the 
fact  that  it  is  above  the  hone..  Inflammation  of  the  bursa  over 
the  olecranon  constitutes  "miner's  elbow."  "  Weaver's  bottom" 
is  an  inflammation  of  the  bursa  over  the  tuber  ischii. 

Treatment.  Leeches,  evaporating  lotions,  counter-irritation, 
and  splinting.     If  suppuration,  free  incision. 

How  do  you  treat  dropsy  of  a  bursa  ? 

This  condition  is  usually  due  to  subacute  inflammation,  or 
long-continued  pressure.  It  may,  at  times,  be  resolved  by 
counter-irritants,  more  commonly  it  will  require  incision  and 
scraping. 

What  is  a  bunion  ? 

A  bursal  enlargement  occurring  in  the  foot.  It  is  usually 
placed  at  the  side  of  the  metatarsal  joint  of  the  great  toe. 

What  is  tenosynovitis  ? 

Inflammation  of  tendons  and  their  sheaths  ;  due  to  traumatism, 
gout,  or  rheumatism.  CJiaracterized  by  a  puffy  swelling  along  the 
tendon,  and  fine  crackling  crepitation.  Treated  by  iodine  or 
blisters. 

What  is  a  ganglion  ? 

A  cyst  formed  in  connection  with  the  sheath  of  a  tendon.  The 
swiple  ganglion  is  developed  on  the  synovial  sheath.  The  com- 
pound ganglion  consists  of  a  dilatation  which  commonly  involves 
the  sheaths  of  several  tendons.  Ganglion  occurs  upon  the  ex- 
tensor tendons  at  the  back  of  the  wrist,  and  in  front  of  the  ankle. 
It  can  be  felt  as  a  round,  tense,  fluctuating,  freely  movable 


DISEASES    OF    BURS^    AND    TENDONS.        257 

tumor,   sometimes  giving  considerable   pain  on   motion,   and 
always  causing  some  loss  of  power. 

Treatment.  Subcutaneous  rupture,  eitlier  by  force  or  by  the 
tenotome.     Incision  and  curetting. 

What  is  paronychia  ? 

Synonyms.     Whitlow.     Felon.     Panaris. 

Definition.  An  acute  septic  inflammation,  involving  the 
sheath  of  the  tendon,  the  tissues  superficial  to  it,  or  the  peri- 
osteum, or  all  these  structures.  Always  due  to  a  septic  wound. 
Characterized  by  intense  pain,  rapid  disorganization,  and  ten- 
dency to  spread  along  the  course  of  the  tendon.  Treated  by 
early,  free  incision,  scraping,  and  thorough  disinfection. 


Onychia. 

What  is  onychia  ? 

Inflammation  of  the  matrix  of  the  nails. 

May  be  simple  onychia  or  "  run  around,"  due  to  injury,  and 
attended  by  suppuration  and  loosening  of  the  nail.  Treated  by 
wet  boric  acid  dressing. 

Malignant  onychia^  due  to  injury  and  profound  constitutional 
depression ;  characterized  by  fungous  ulcerations,  showing  no 
tendency  to  heal.  Treated  by  trimming  the  nail,  and  applying 
powdered  nitrate  of  lead  to  the  granulations. 

What  is  ingrowing  toe  nail  ? 

An  ulceration,  caused  by  tight  shoes  pressing  the  soft  part  of 
the  toe  against  the  edge  of  the  toe  nail.     Remedied  by  wearing 
loose  shoes,  packing  absorbent  cotton  and  iodoform  between  the 
soft  parts  and  the  nail,  or  by  avulsing  the  nail. 
17 


258  ESSENTIALS    OF    SURGERY, 


ANJESTHETICS. 

What  substances  are  used  to  produce  anaesthesia  ? 

General  anaesthesia  is  induced  by  nitrous  oxide,  chloroform, 
or  ether.     Local  anaesthesia  is  induced  by  cocaine  or  freezing. 

Which  is  the  safest  general  anaesthetic  ? 

Nitrous  oxide  for  brief  operations  (one  minute),  ether  for  ma- 
nipulations requiring  more  time. 

What  is  the  danger  in  chloroform  inhalation  ? 

Cardiac  syncope.  It  may  attack  the  robust  and  apparently 
healthy.  Particularly  liable  to  occur  when  operations  about  the 
anus  are  begun  before  complete  anaesthesia. 

How  do  you  prepare  patients  for  the  administration  of  anaes- 
thetics ? 

Give  no  food  for  six  hours  before  the  time  of  administration. 
Examine  the  urine,  and  carefully  auscult  the  lungs  and  heart. 
Half  an  hour  before  the  administration  of  the  anaesthetic  give  a 
full  dose  of  whiskey  or  wine.  See  that  there  are  no  artificial 
teeth  or  foreign  bodies  in  the  mouth.  Loosen  the  clothing  about 
the  neck  and  chest.  In  drunkards  the  anaesthetic  should  be  pre- 
ceded by  a  quarter  of  a  grain  of  morphia. 

How  do  you  administer  ether  ? 

Use  a  folded  towel,  or  one  of  the  many  inhalers.  The  recum- 
bent position  should  be  enforced.  Protect  the  eyes  by  a  folded 
towel.  Let  the  vapor  be  very  dilute  for  the  first  few  inhalations, 
increasing  the  strength  as  the  patient  loses  consciousness.  Per- 
sistent cough  is  most  quickly  overcome  by  pushing  the  ether. 
Watch  the  respiration  and  pulse.  "When  the  pulse  is  slow  and 
full,  the  respirations  deep  and  snoring,  the  reflex  irritability 
abolished,  and  the  patient  totally  relaxed,  the  anaesthesia  is  car- 
ried to  the  limit  of  safety. 

What  accidents  may  occur  during  the  administration  of  ether  ? 

In  the  first  stage  there  may  be  respiratory  forgetfulness^  or  a 
cessation  of  breathing  efforts,  though  consciousness  is  still  pre- 


ANESTHETICS.  259 

served.  Corrected  by  sudden  pressure,  or  a  dasli  of  ether  over 
the  epigastrium. 

In  the  third  stage  mucus  may  collect  in  the  throat  to  such  an 
extent  as  to  embarrass  respiration  ;  it  should  be  mopped  out  by 
sponges  tied  to  sticks.  If  there  is  vomiting,  the  head  should  be 
turned  to  the  side.  If  the  air  does  not  enter  the  lungs  freely,  the 
lower  jaw  should  be  pushed  forward  by  the  fingers  placed  be- 
neath the  ramus. 

There  may  be  threatened  asphyxia,  from  excess  of  ether,  drop- 
ping back  of  the  tongue,  or  closure  of  the  glottis.  Denoted  by 
irregular  pulse,  laryngeal  stertor,  blue  surface,  absence  of  respi- 
ratory movements.  Immediately  push  the  angles  of  the  jaw 
forward  or  draw  the  tongue  out  of  the  mouth,  practise  artificial 
respirations,  dash  ether  over  the  epigastrium,  raise  the  foot  of  the 
bed  or  table,  and  apply  the  two  poles  of  a  battery,  one  to  the  right 
phrenic  in  the  neck  and  the  other  to  the  sixth  intercostal  space, 
closing  the  circuit  during  the  inspiratory  movement  of  artificial 
respiration.  Tracheotomy  may  be  performed  and  the  lungs  in- 
flated directly. 

What  precautions  are  taken  during  the  administration  of  ether  ? 

Lights,  if  near,  should  always  be  held  above  the  level  of  the 
ether.  A  third  person  should  always  be  present  when  women 
are  etherized. 

What  are  the  indications  for  allowing  the  patient  more  air  ? 

A  feeble  infrequent  pulse.  Lividity  of  the  surface.  Laryn- 
geal stertor.  Pallor  and  tonic  spasm.  A  pupil  fixed  in  dilata- 
tion (always  a  sign  of  great  danger). 

Under  what  circumstances  is  chloroform  preferred  to  ether  ? 

When  there  is  emphysema  of  the  lungs,  bronchitis,  kidney 
disease,  or  vascular  degeneration.  In  infants.  In  operations 
about  the  mouth. 

How  do  you  administer  chloroform  ? 

The  vapor  must  not  be  stronger  than  four  parts  to  the  hundred 
of  air^  Pour  a  few  drops  upon  a  piece  of  lint  or  a  towel  and 
hold  it  a  short  distance  from  the  mouth  and  nose.  Watch  the 
pulse  most  carefully. 


260  ESSENTIALS    OF    SURGERY. 

How  do  you  treat  syncope  in  chloroform  narcosis? 

Pull  the  tongue  forward.  Raise  the  foot  of  the  table  high  up. 
Dash  cold  water  over  the  face  and  chest.  Begin  artificial  res- 
piration immediately. 

Should  you  give  ether  in  shock  ? 

As  ether  directly  lowers  the  temperature,  it  should  not  be  given 
when  shock  is  marked.  After  restoration  of  temperature  and 
full  drugging  with  whiskey  and  opium,  a  minimum  quantity  will 
be  required,  and  may  be  cautiously  administered. 


LIGATION    OF    ARTERIES.  261 


LIGATION  OF  ARTERIES. 

Under  what  circumstances  is  an  artery  ligated  in  its  conti- 
nuity ? 

1.  Ill  the  treatment  of  aneurism. 

2.  In  the  checking  of  bleeding,  under  certain  circumstances. 

3.  In  the  treatment  of  inflammation. 

What  instruments  are  required  for  the  operation  ? 

Scalpel,  dissecting  and  artery  forceps,  blunt  hooks,  retractors, 
grooved  director,  aneurism  needle,  ligature,  needles,  and  dres- 
sings. All  should  be  arranged  in  trays  and  covered  with  car- 
bolic solution  1:20  ;  which  is  diluted  up  to  1:40,  when  the  ope- 
ration is  begun. 

Describe  the  ligatures  and  dressings. 

Ligature  of  antiseptic,  prepared  cat-gut.  After  operation,  the 
wound,  if  small,  is  closed  without  drainage  ;  if  large,  it  is  drained 
by  means  of  rubber  tubes,  horsehair,  or  strands  of  cat-gut.  Its 
edges  are  closely  approximated,  and  the  whole  covered  in  by  a 
careful  antiseptic  dressing. 

What  precautions  are  taken  in  performing  the  operation? 

1.  Begin  and  end  the  superficial  cut  with  the  knife-blade  ver- 
tical to  the  surface,  thus  avoiding  "heeling." 

2.  Divide  the  deep  fascia  to  the  full  extent  of  the  superficial 
cut.  Open  the  sheath  by  cutting  tcnoard  the  dissecting  forceps^  in 
which  a  portion  of  its  periphery  is  pinched  up.  The  incision  is 
subsequently  enlarged  by  the  director.  Avoid  forcible  tearing 
or  wide  separation  of  the  artery  from  its  sheath.  Pass  the  an- 
eurism needle  from  the  side  where  the  most  important  and  vul- 
nerable structures  are  placed.  Before  tying,  compress  the  artery 
and  feel  for  pulsation  below,  to  be  sure  that  the  circulation  is 
controlled. 

In  securing  the  ligature,  make  more  tension  upon  the  first 
than  upon  the  second  knot. 

What  complications  may  arise  in  the  after-treatment  of  liga- 
tion? 

Gangrene,  hemorrhage,  return  of  i)ulsation  in  aneur.Bm. 


262  ESSENTIALS    OF    SURGERY. 

Describe  the  after-treatment  of  ligation. 

Elevate  the  limb  and  surround  it  with  a  thicJc  layer  of  wool. 
Keep  at  absolute  rest.  Light,  nutritious  diet.  Strict  quiet, 
botli  mental  and  physical. 

Describe  the  triangles  of  the  neck. 

Anterior  triangle.  In  front,  the  middle  line.  Behind,  the 
sterno-cleido-mastoid.  Above,  the  base  of  the  lower  jaw,  and 
a  line  from  its  angle  to  the  mastoid  process.  Apex,  at  the 
sternum.  Subdivided  into  three  smaller  triangles  by  the  digas- 
tric above,  and  the  anterior  belly  of  the  omo-hyoid  below,  named 
from  below  up,  the  inferior  carotid.,  the  superior  carotid^  and 
the  subraaxillary. 

Inferior  carotid  triangle.  In  front,  middle  line.  Behind, 
sterno-mastoid.     Above,  anterior  belly  of  omo-hyoid. 

Superior  carotid  triangle.  Behind,  sterno-mastoid.  Below,  an- 
terior belly  of  omo-hyoid.     Above,  posterior  belly  of  digastric. 

Submaxillary  triangle.  Above,  body  of  jaw,  parotid  gland, 
and  mastoid  process.  Below,  posterior  belly  of  digastric,  and 
stylo-hyoid.     In  front,  median  line. 

Posterior  triangle.  In  front,  sterno-mastoid.  Behind,  trape- 
zius. Below,  clavicle.  Apex,  at  occiput.  Divided  by  the  poste- 
rior belly  of  the  omo-hyoid  into  an  upper  or  occipital,  and  a 
lower  or  subclavian  triangle. 

Occipital  triangle.  In  front,  sterno-mastoid.  Behind,  trape- 
zius.    Below,  omo-hyoid. 

Subclavian  triangle.  Above,  posterior  belly  of  omo-hyoid.  Be- 
low clavicle.     In  front,  sterno-mastoid. 

Common  carotid.  Origin — right,  from  the  innominate,  behind 
the  sterno-clavicular  articulation  ;  left,  from  the  arch  of  the 
aorta,  more  deeply  placed.  Extent— ivom.  behind  the  sterno- 
clavicular articulation  to  the  upper  margin  of  the  thyroid  carti- 
lage. The  carotid  artery  lies  in  the  same  sheath  with  the 
internal  jugular  vein  and  the  pneumogastric  nerve,  each  of  these 
structures  being  separated  from  the  other  by  fibrous  septa,  and 
having  a  distinct  compartment.  The  sheath  rests  upon  the  lon- 
gus  colli,  and,  in  the  upper  part  of  its  course,  the  rectus  capitis 
anticus  muscles,  and  is  crossed  at  the  level  of  the  cricoid  carti- 
lage by  the  omo-hyoid  muscle. 


LIGATION    OF    ARTERIES. 


263 


Line.  From  the  sterno-clavicular  articulation  to  a  point  mid- 
way between  the  angle  of  the  jaw  and  the  mastoid  process. 
Superficial  guide — anterior  border  of  sterno-cleido-mastoid. 

Belations.  Anterior.  Skin,  superficial  fascia,  platysma,  deep 
fascia,  sterno-hyoid,  sterno-thyroid,  sterno-mastoid  muscles  ;  su- 

Fig.  59. 


Lines  of  incision  for  carotid,  facial,  lingual,  subclavian,  and  axillary  arteries. 

perior  and  middle  thyroid,  and  anterior  jugular  veins ;  descen- 
dens  noni  and  communicans  noni  nerves.  Posterior. — Longus 
colli  and  rectus  capitis  anticus  muscles  ;  sympathetic,  recurrent 
laryngeal  nerves  ;  inferior  thyroid  artery.  Internal. — Trachea, 
(jesophagus,  larynx,  pharynx,  recurrent  laryngeal  nerve,  and 
inferior  thyroid  artery.  External. — Internal  jugular  vein,  infe- 
rior thyroid  artery.  On  the  left  side  the  internal  jugular  vein 
is  somewhat  anterior  to  the  artery. 

Collateral  circulation.  Inferior  with  superior  thyroids,  ascend- 
ing branch  of  transvorsalis  colU  with  princeps  cervicis,  terminal 
branches  of  internal  and  external  carotids  on  the  two  sides. 

Operation,  above  the  omo-hyoid.  Patient  supine  with  a  pillow 
under  the  shoulders  and   neck,   head  extended,   face  turned 


26*1  ESSENTIALS    OF    SURGERY. 

towards  sound  side.  Incision,  three  inches,  along  the  anterior 
border  of  the  sterno-cleido-mastoid  muscle,  and  with  its  centre 
on  a  level  with  the  cricoid  cartilage.  Divide  skin,  superficial 
fascia,  platysyna,  deep  fascia.  With  retractors  draw  aside  the 
sterno-raastoid.  Expose  the  omo-hyoid  by  cutting  through  a 
dense  fascia  covering  it  and  the  sheath  of  the  vessels,  carefully 
avoiding  the  venous  plexus  formed  by  the  superior  thyroid  with 
its  communications  from  the  Ungual,  facial,  anterior  and  ex- 
ternal jugular.  The  sheath  of  the  artery  is  found  bisecting  the 
angle  made  by  the  anterior  belly  of  the  omo-hyoid  and  the 
anterior  border  of  the  sterno-mastoid.  Open  the  inner  compart- 
ment of  the  sheath,  avoiding  descendens  and  communicans  noni 
nerves,  and  pass  the  ligature  from  without  inward. 

External  carotid.  A  branch  of  the  common  carotid,  given 
off  at  upper  border  of  thyroid  cartilage.  It  extends  from  the 
superior  border  of  thyroid  cartilage,  to  neck  of  condyle  of  lower 
jaw. 

Chief  relations.  Anterior.  Hypoglossal  nerve,  lingual  and 
facial  veins,  digastric  muscle.  Posterior.  Superior  laryngeal 
and  glosso-pharyngeal  nerves.  Internal.  Hyoid  bone  and 
pharynx.  External.  Internal  carotid  artery  and  internal  jugu- 
lar vein. 

Collateral  circulation.  Lingual,  superior  thyroid,  occipital, 
and  the  same  of  the  opposite  side. 

Operation.  Incision  midway  between  angle  of  jaw  and  ante- 
rior border  of  sterno-cleido-mastoid  muscle,  carried  down  three- 
eighths  of  an  inch  in  front  of  the  latter  to  one-half  inch  below 
upper  border  of  thyroid  cartilage.  Divide  skin,  superficial  fascia, 
and  platysma  at  once.  Slit  up  the  deep  fascia  spreading  from 
the  anterior  border  of  the  sterno-cleido-mastoid,  avoiding  the 
external  jugular,  temporal,  and  facial  veins.  By  blunt  dissection 
the  parotid  gland  and  the  posterior  belly  of  the  digastric  are  ex- 
posed ;  the  latter  is  drawn  upward  with  blunt  hooks,  when  the 
external  carotid  is  found,  crossed  by  the  hypoglossal  nerve,  with 
the  superior  laryngeal  nerve  lying  beneath. 

Pass  the  needle  from  without  inward. 

Lingual.  Is  given  off  from  the  external  carotid  between  the 
superior  thyroid  and  facial. 


LIGATION    OF    ARTERIES.  265 

In  the  first  part  of  its  course,  from  its  origin  to  the  posterior 
border  of  the  hyoglossus,  it  passes  obliquely  up  and  in  to  the 
great  cornu  of  the  hyoid  bone,  and  is  covered  simply  by  skin, 
fasciae,  platysma,  and  veins,  resting  on  the  middle  constrictor. 
In  the  second  part  of  its  course,  beneath  the  hyoglossus  muscle, 
it  runs  parallel  with  the  great  horn  of  the  hyoid,  then  ascends  to 
the  tongue.  It  is  crossed  here  by  the  posterior  belly  of  the 
digastric  and  the  stylo-hyoid  muscles,  and  is  covered  by  the 
hyoglossus  muscle. 

CJiief  relations.  Anterior.  Hyoglossus  muscle.  Posterior. 
Middle  constriction  of  pharynx,  and  genio-hyoglossus  muscle. 
Above.  Hypoglossal  nerve.  Below,  Tendon  of  digastric,  and 
great  horn  of  hyoid  bone. 

Point  of  election.  Second  part  of  artery,  lying  beneath  hyo- 
glossus. 

Ojjeration.  Incision  three  inches  ;  begin  a  little  below  and 
internal  to  the  symphysis  menti,  convex  downward  to  the  great 
horn  of  the  hyoid,  and  outward  to  the  inner  border  of  the  sterno- 
mastoid.  The  three  outer  layers  being  divided  the  submaxillary 
gland  is  reached,  lying  in  the  deep  fascia  ;  the  latter  is  divided 
and  the  gland  turned  up  exposing  the  tendon  of  the  digastric, 
and  the  hypoglossal  nerve  above  ;  the  nerve  is  dissected  up  and 
retracted  exposing  the  hyoglossus  muscle,  which,  when  divided 
upon  a  director,  enables  the  operator  to  pass  the  ligature  about 
the  artery  from  above  downwards.  Superficial  guide,  great  horn 
of  hyoid.     Deep  guide,  nerve  and  tendon. 

Facial  arises  from  external  carotid,  a  little  above  the  lingual, 
passes  beneath  the  posterior  belly  of  the  digastric  and  stylo- 
hyoid muscles  and  hypoglossal  nerve,  winds  through  a  groove  in 
the  posterior  and  upper  border  of  the  submaxillary  gland,  and 
crosses  the  lower  jaw  in  a  slight  depression  just  in  front  of  the 
insertion  of  the  masseter  muscle.  Here  is  the  point  of  election  ; 
the  artery  is  covered  at  this  point  by  skin  fascia  and  platysma. 

Oprration .  Incision  one  inch,  just  on  the  jaw,  along  the 
anterior  border  of  the  masseter  muscle  ;  vein  lies  posteriorly. 
Pass  the  thread  from  behind  forward.  Guides.  vVnterior  edorc  of 
masseter  muscle,  and  groove  in  the  submaxillary  bone. 


266  ESSENTIALS    OF    SURGERY. 

Occipital  arises  from  the  external  carotid  opposite  the  facial, 
and  passes  backwards  under  the  posterior  belly  of  the  digastric, 
the  stylo-hyoid,  and  the  lower  part  of  the  parotid  gland,  across 
the  internal  carotid  artery,  internal  jugular  vein,  and  the  pneu- 
mogastric  and  spinal  accessory  nerves.  The  hypoglossal  nerve 
hooks  around  it  beneath  the  gland.  The  artery  ascends  the 
neck  to  the  level  of  the  transverse  process  of  the  atlas,  passes 
through  a  groove  on  the  mastoid  process  of  the  temporal  bone, 
beneatli  the  sterno-mastoid,  splenius,  digastric,  and  trachleo- 
mastoid,  pierces  the  insertion  of  the  splenius,  and  becomes  super- 
ficial. 

Operation.  Point  of  election.  Occipital  portion.  Incision  from 
the  apex  of  the  mastoid  process  backward  and  very  little  upward 
for  two  inches.  Divide  skin,  superficial  fascia,  deej)  fascia,  and 
outer  border  of  the  sterno-mastoid,  the  splenius,  the  complexus. 
Guides.  Transverse  process  of  the  atlas,  and  the  mastoid  process  ; 
the  artery  is  found  between  the  two,  and  can  be  traced  outward 
to  a  more  superficial  position.  Isolate  from  the  occipital  vein, 
and  ligate. 

Temporal.  A  terminal  of  the  external  carotid.  It  lies  in  the 
space  between  the  condyle  of  jaw  and  external  auditory  meatus. 

Line.  Directly  upward,  between  the  condyle  of  jaw  and  the 
cartilage  of  the  ear. 

Chief  relations.  Anterior.  Branches  of  facial  and  auriculo-tem- 
poral  nerves.  Posterior.  Yein,  and  facial  and  auriculo-temporal 
nerves.  As  it  crosses  the  root  of  the  zygoma,  the  artery  is  cov- 
ered by  a  dense  fascia  derived  from  the  parotid  gland,  this 
should  not  be  opened. 

Operation.  Incision  vertical,  one  inch  long,  between  the  car- 
tilage of  the  ear  and  the  condyle  of  the  jaw.  Skin,  superficial 
fascia,  and  some  fibres  of  the  attrahens  aurem  are  divided, 
artery  freed,  and  thread  passed  from  behind  forward. 

Subclaviail.  On  the  right  side  from  the  innominate.  On  the 
left  side  from  the  arch  of  the  aorta.     Three  portions — 

1.  From  its  origin  to  inner  border  of  scalenus  anticus.  This 
portion  gives  off  the  thyroid  axis,  the  vertebral,  and  the  internal 
mammary  arteries. 


LIGATION    OF    ARTERIES.  267 

2.  Behind  the  scalenus  anticus.  Gives  off  superior  intercostal 
artery  on  the  right  side. 

3.  Outer  edge  of  scalenus  anticus  to  lower  border  of  first  rib. 
Point  of  election  is  the  outer  third. 

Relations  of  the  outer  third.  Posterior.  Scalenus  medius.  Above 
and  external.  Brachial  plexus.  Anterior  and  below.  Subclavian 
vein.  Internal.  Edge  of  scalenus  anticus.  Structures  lying  in 
front.  Skin,  superficial  fascia,  platysraa,  deep  fascia,  a  plexus 
of  veins  formed  by  the  external  jugular,  suprascapular,  and 
transversalis  colli ;  clavicle  and  subclavius  muscle ;  suj^rascapu- 
lar  artery. 

Operation.  Position  of  patient,  recumbent,  shoulder  supported 
on  pillows,  head  back,  face  toward  sound  side,  arm  of  the  affected 
side  depressed  as  much  as  possible.  Superficial  guide^  most  promi- 
nent part  of  clavicle.  Deep  guides.,  brachial  plexus  above  and 
behind,  outer  edge  of  scalenus  anticus  muscle,  and  tubercle  of 
first  rib  internal.  Incision.  The  skin  is  drawn  down  from  the 
neck  over  the  clavicle,  and  a  three-inch  incision  made  upon  the 
bone,  from  the  external  border  of  the  sterno-raastoid  muscle  out- 
wards. On  releasing  the  skin  this  wound  hes  somewhat  above 
the  clavicle.  Secure  or  push  aside  the  external  jugular  vein, 
open  the  deep  fascia,  feel  for  the  tubercle  of  the  first  rib  and 
the  outer  border  of  the  anterior  scalene  muscle  ;  free  the  artery 
by  blunt  dissection,  and  pass  the  thread  from  below. 

Collateral  circulation.  Suprascapular  artery  and  posterior 
scapular,  branch  of  the  transversalis  colli  with  the  subscapular 
and  circumflex.  Internal  mammary,  superior  intercostal,  and 
aortic  intercostals,  with  the  long  and  short  thoracics. 

First  part  of  subclavian  artery.  Bight  side.  In  front.  Skin, 
superficial  fascia,  platysma,  and  deep  fascia.  Three  muscles, 
sterno-mastoid,  sterno-hyoid,  sterno-thyroid.  Three  veins, 
internal  jugular,  vertebral,  anterior  jugular.  Three  nerves, 
vagus,  cardiac  filaments  of  sympathetic,  phrenic.  Behind. 
Longus  colli,  and  three  nerves,  sympathetic  cardiac  branches 
of  vagus  and  recurrent  laryngeal.  Below.  Pleura  and  recur- 
rent laryngeal. 

Lfft  side.  Longer,  more  deeply  placed,  ascends  almost  verti- 
cally to  neck.     In  front.     Pleura,  lung,  internal  jugular  aod 


268  ESSE^^TIALS    OF    SURGERY. 

innominate  veins,  the  same  muscles  and  nerves  as  on  the  right 
side.  Behind.  (Esophagus,  thoracic  duct,  and  as  on  right  side 
except  tlie  recurrent  laryngeal.  Inner  side.  CEsophagus,  trachea, 
thoracic  duct.     Outer  side.     Pleura  and  lung. 

Second  part  of  the  subclavian.  Rests  between  the  anterior  and 
middle  scalene  muscles,  with  brachial  plexus  above;  phrenic 
nerve,  transversalis  colli  and  suprascapular  arteries  in  front; 
and  pleura  below. 

Internal  mammary.  Arises  from  the  first  portion  of  the  sub- 
clavian and  passes  down  behind  costal  cartilages  to  sixth  inter- 
space. Line  of  incision  is  vertical,  two  and  ©ne-quarter  inches 
long,  beginning  at  lower  border  of  clavicle  one-quarter  of  an  inch 
external  to  margin  of  sternum ;  or  the  incision  may  be  trans- 
verse. The  point  of  election  is  in  the  first  three  intercostal 
spaces. 

Chief  relations.  Anterior.  Costal  cartilages  and  internal 
intercostal  muscles.  Posterior.  Pleura.  As  it  is  about  to  enter 
the  chest  it  is  crossed  by  the  phrenic  nerve. 

Axillary.  Continuation  of  the  subclavian.  Extends  from  the 
lower  border  of  the  first  rib  to  the  lower  border  of  the  insertion 
of  the  teres  major. 

Course.  With  abducted  arm,  from  the  middle  of  the  clavicle  to 
the  inner  border  of  the  coraco-brachialis  muscle.  Three  portions — 

1.  Lower  border  of  first  rib  to  upper  border  of  pectoralis 
minor.  Branches.  Superior  thoracic,  acromio-thoracic  ;  the  latter 
runs  along  the  upper  border  of  the  pectoralis  minor. 

2.  Behind  pectoralis  minor.  Branches.  Long  thoracic,  at  the 
lower  border  of  the  pectoralis  minor,  alar  thoracic. 

3.  Prom  lower  border  of  pectoralis  minor  to  insertion  of  latis- 
simus  dorsi  and  teres  major.  Branches,  subscapular  running  in 
the  posterior  axillary  fold,  posterior  circumflex,  anterior  circum- 
flex. 

Points  of  election.  First  and  third  portions,  particularly  the 
last. 

Operation.  First  part.  Patient  supine,  arm  carried  from  the 
side.  Incision  three  inches,  commencing  one-half  inch  from  the 
sterno-clavicular  articulation,  extending  outward  along  the  line 


LIGATION    OF    ARTEBIES.  269 

between  tlie  sternal  and  clavicular  portions  of  pectoralis  major. 
Work  upward  and  backward  between  the  two  portions  of 
the  pectoral  muscle  till  a  dense  fascia,  the  costo-coracoid,  is 
reached  ;  depress  the  shoulder  and  tear  the  fascia  with  the 
director,  when  the  axillary  vein  is  found  ;  behind  it  is  the  arterj^ 
and  still  deeper  the  brachial  plexus.  Pass  the  ligature  from  below. 
Guides.  The  brachial  plexus  behind  and  above.  Subclavian  vein, 
below  and  in  front.     Inner  border  0/ pectoraZis  minor ^  externally. 

Third  'portion.  Arm  abducted  and  supinated.  Incision  three 
inches  long,  in  the  hollow  of  the  armpit,  along  a  line  passing  from 
the  junction  of  the  anterior  and  middle  third  of  the  axilla  to  the 
middle  of  the  bend  of  the  elbow.  Divide  skin,  superficial  and 
deep  fascias  ;  relax  by  bending  the  elbow,  displace  the  median 
nerve  to  the  outer  side,  the  axillary  vein  with  the  ulnar  and 
internal  cutaneous  nerves  to  the  inner  side.  Open  the  sheath, 
and  pass  the  thread  from  the  inner  side. 

Belations.  In  front.  Skin  and  fascia  only  at  lower  part  of  its 
course.  At  the  upper  part,  pectoralis  major,  internal  cutane- 
ous nerve,  inner  head  of  median.  Behind.  Subscapularis, 
tendon  of  latissimus  dorsi  and  teres  major,  musculo-spiral  and 
circumflex  nerves.  Outer  side.  Coraco-brachialis,  median  nerves, 
musculo-cutaneous  nerve.  Inner  side.  Ulnar  nerve,  nerve  of 
Wrisburg,  axillary  vein.  Guides.  .  Superficial,  the  coraco- 
brachialis.     Deep,  the  branches  of  the  brachial  plexus. 

Collateral  circulation.  Ligation  of  first  part.  Acromio- thoracic 
and  superior  thoracic  with  subscapular  and  circumflex.  Long 
thoracic  with  intercostals  and  internal  mammary. 

Ligation  of  third  part.  Posterior  circumflex  and  subscapular 
with  superior  profunda  ;  anastomoses  through  muscular  branches 
and  through  the  bone. 

Brachial.  Continuation  of  the  axillary,  from  the  lower  bor- 
der of  the  teres  major,  along  the  inner  and  anterior  aspect  of  arm 
to  one-half  inch  below  the  bend  of  the  elbow.  Passes  along  the 
inner  border  of  biceps  and  coraco-brachialis,  which  arc  its  mus- 
cles of  reference.,  or  guides. 

Chi(f  relaXi&iis.  Anterior.  Skin  and  fascia;  at  middle  third 
mfdifui  nerve  ;  at  low(;r  third,  bicipital  fascia  with  median  basilic 


270 


ESSENTIALS    OF    SURGERY. 


Fig.  60. 


vein  resting  on  it.  Posterior.  Long  head  of  triceps,  insertion  of 
coraco-brachialis,  brachialis  anticus,  musculo-spiral  nerve,  supe- 
rior profund  artery.  Inner  side.  Internal  cutaneous  and  ulnar 
nerves,  median  nerve  (below),  basilic  vein.  Outer  side.  Median 
nerve  (above),  coraco-brachialis  and  biceps.  The  median  nerve 
first  to  the  outer  side,  passes  in  front,  then  to  the  inner  side. 
Branches^  1  muscular,  2  superior  profund,  accompanying  mus- 
culo-spinal  nerve,  3  inferior  profund,  accompanying  the  ulnar 
nerve,  4  nutrient,  5  anastomotica  magna. 

Operation.     Arm  extended  and  everted.  Incision  three  inches, 
along  the  inner  border  of  the  biceps,  or  in  the  line  of  the  artery  - 

(from  the  junction  of  the  anterior 
and  middle  third  of  the  axilla,  to 
the  middle  of  the  bend  of  the  el- 
bovs^).  Avoid  the  median  basilic 
vein  if  it  lies  in  the  superficial  fas- 
cia at  the  seat  of  operation. 

At  the  bend  of  the  elbow.  Incision 
three  inches.  One-half  inch  inter- 
nal to  the  tendon  of  the  biceps,  the 
lower  end  lying  over  the  neck  of 
the  radius.  Divide  skin,  superfi- 
cial fascia,  bicipital  fascia,  avoid- 
ing or  tying  the  median  basilic 
vein.  The  artery  is  exposed,  lying 
upon  the  brachialis  anticus,  with 
the  biceps  tendon  to  its  outer,  the 
pronator  radii  teres  muscle  to  its 
inner  side. 

Collateral  circulation.  Circum- 
flex and  subscapular  with  supe- 
rior profund  ;  profund  with  radial 
ulnar  and  interosseous  recurrents. 


Relation  of  brachial  artery  to 
bicipital  fascia,  internal  cutane- 
ous nerve,  and  median  basilic  vein 
at  the  bend  of  the  elbow. 


S,adial.  A  terminal  of  the 
brachial,  passes  from  one-half  inch 
below  bend  of  elbow,  along  radial 
side  of  forearm  to  wrist,  winds 
backwards  around  outer  side  of 


LIGATION    OF    ARTERIES.  271 

carpus  beneath  extensors  of  thumb,  and  enters  palm  of  hand 
beneath  the  two  heads  of  the  first  dorsal  interosseous  muscle. 
Line.  From  middle  of  bend  of  elbow  to  a  point  midway  be- 
tween tendon  of  flexor  carpi  radialis,  and  styloid  process  of  ra- 
dius.    Guide.  Iriner  border  of  supinator  longus. 

Chief  relations.  Upper  third.  External,  supinator  longus  mus- 
cle ;  internal,  pronator  radii  teres.  Lower  tivo-thirds.  External, 
supinator  longus  ;  internal,  flexor  carpi  radialis.  In  the  middle 
third  the  radial  nerve  is  to  the  radial  side  of  the  artery. 

Operation.  Division  of  skin  and  fascial  only  ;  the  artery  is 
superficially  placed  in  the  muscular  interspace. 

Ulnar.  A  terminal  of  the  brachial.  Commences  one-half  inch 
below  middle  of  bend  of  elbow,  crosses  obliquely  to  ulnar  side  of 
arm,  and  continues  along  its  ulnar  border  to  the  wrist. 

Line.  From  a  point  at  junction  of  upper  and  middle  thirds 
of  forearm,  and  three-fourths  of  an  inch  external  to  ulnar  border, 
to  the  radial  border  of  pisiform  bone. 

Chief  relations.  Below,  flexor  profundus  digitorum  ;  external, 
flexor  sublimis  digitorum  ;  internal,  flexor  carpi  ulnaris  and  ul- 
nar nerve.  In  the  upper  third  of  its  course  it  lies  beneath  the 
superficial  set  of  flexor  muscles.  In  the  lower  two-thirds,  in 
its  muscular  interspace  beneath  the  superficial  and  deep  fascia 
only. 

Operation.  Pass  the  needle  from  within  outwards.  Guide — 
flexor  carpi  ulnaris. 

Palmar  arches.  Superficial.  Direct  continuation  of  the  ulnar 
artery,  convex  downwards,  completed  by  the  superficialis  volse 
of  the  radial,  or  the  radialis  indicis.  Beneath  it  lie  the  digital 
arteries,  nerves,  and  tendons  of  the  flexor  sublimis  digitorum. 

Deep.  The  direct  continuation  of  the  radial,  completed  by  the 
profunda  branch  of  the  ulnar  ;  it  rests  upon  the  palmar  inter- 
ossei,  and  metacarpal  bones  near  their  carpal  ends.  It  lies 
beneath  the  arteries,  nerves,  and  tendons  of  both  superficial  and 
deep  flexors. 

Position  of  the  arches.  The  superficial  lies  in  a  line  drawn 
directly  across  the  palm  of  the  hand,  from  the  angle  of  junction 
of  skin  covering  the  inner  border  of  the  thumb  and  the  outer 


272  ESSENTIALS    OF    SURGERY. 

border  of  the  metacarpal  bone  of  the  index-finger.     The  deep 
arch  hes  a  finger -s  breadth  nearer  the  wrist. 

External  iliac.  A  branch  of  the  common  iUac.  Its  course  is 
represented  by  the  lower  two-thirds  of  a  line  drawn  from  three- 
fourths  of  an  inch  below  and  to  the  left  side  of  Ehe  umbilicus,  to 
a  point  midway  between  the  anterior  superior  spinous  process 
of  the  ilium  and  the  symphysis  pubis.  Just  above  Poupart's  liga- 
ment it  gives  off"  the  deep  epigastric,  and  the  deep  circumflex 
iliac. 

Chief  relations.  Anterior.  Peritoneum,  spermatic  vessels,  vas 
deferens,  genital  branch  of  genito-crural  nerve,  circumflex  iliac 
vein.  Posterior.  Psoas  magnus  and,  on  the  right  side,  the  ex- 
ternal iliac  vein.  External.  Psoas  magnus.  Internal.  External 
iliac  vein  and  vas  deferens. 

Operation.  Patient  recumbent,  shoulders  raised,  knees  and 
thighs  flexed.  Incision.  From  one  inch  above  anterior  superior 
spinous  process  ilium,  to  external  abdominal  ring,  parallel  to 
Poupart's  ligament.  Pass  the  needle  from  within  outwards,  and 
avoid  including  the  genital  branch  of  the  genito-crural  nerve. 

Collateral  circulation.  Gluteal  and  obturator  with  external 
circumflex.  Sciatic  with  superior  perforating  and  circumflex 
branches  of  profunda.  The  deep  circumflex  iliac  with  the  ilio- 
lumbar, the  lower  intercostals,  and  the  lumbar  branches  of  the 
aorta.  Internal  pudic  with  the  external  pudic  and  internal  cir- 
cumflex. Mammary,  inferior  intercostals,  and  obturator  with 
deep  epigastric. 

Femoral.  The  direct  continuation  of  the  external  iliac,  and 
extends  from  the  middle  of  Poupart's  ligament  to  the  opening 
in  the  adductor  magnus.  Its  upper  part  is  a  little  internal  to  the 
head  of  the  femur ;  its  lower  part  lies  to  the  inner  side  of  the 
shaft  of  the  bone. 

In  Scarpa's  triangle  it  is  superficial.  Below  it  is  more  deeply 
seated,  and  is  in  Hunter's  canal. 

Line.  From  middle  of  Poupart's  ligament  to  inner  side  of 
Internal  condyle. 


LIGATION    OF    ARTERIES, 


273 


Branches.  Superficial 
epigastric,  superficial 
circumflex  iliac,  exter- 
nal pudic,  profunda, 
femoris,  anastomotica 
magna. 

Point  of  election.  Apex 
of  Scarpa's  triangle. 

Belations.  Behind. 
Psoas,  pectineus,  femo- 
ral vein,  adductor  lon- 
gus,  adductor  magnus.  ^ 
Inner  side.  Femoral 
vein,  adductor  longus, 
sartorius.  Outer  side. 
Psoas,  vastus  internus, 
femoral  vein,  internal 
cutaneous  and  long  sa- 
phenous nerves.  In 
front.  Skin,  superficial 
and  deep  fascia,  internal 
cutaneous  and  long  sa- 
phenous nerves,  sarto- 
rius. The  vein  lies  first  f5> 
to  the  inner  side  of  the 
artery,  at  the  apex  of 
Scarpa's  triangle  he- 
hind,  in  Hunter's  canal 
to  the  outer  side. 

Operation.      Point   of    ^ 
election.      Thigh    flexed 
and    rotated    outward, 
knee  bent.  Incisifmfour   ^ 
inches  in  the  course  of 
the  vessel,  its  centre  at 

L.ineB  of  incision  for  liga- 
tion of  femoral,  tibial,  and 
dorsallfl  peclia  arteries. 

IS 


Fig.  61. 


274  ESSENTIALS    OF    SURGERY. 

the  apex  of  Scarpa's  triangle.  On  dividing  the  deep  fascia,  draw 
the  sartorius  outwards.  The  sheath  of  the  vessel  is  cleared,  and 
the  thread  passed /rom  the  vein. 

Hunter''s  canal.  Incision  four  inches  exactly  in  the  middle 
third  of  the  thigh,  and  somewhat  internal  to  the  line  of  the 
artery.  Draw  the  sartorius  inwards,  open  Hunter's  canal  from 
above,  avoiding  the  long  saphenous  nerve,  free  the  artery,  and 
pass  the  thread  from  without  inwards. 

Scarpa's  triangle  is  a  space  situated  at  the  upper  third  of  the 
anterior  surface  of  the  thigh.  Base,  Poupart's  ligament.  Outer 
boundary,  inner  border  of  sartorius.  Inner  boundary,  adductor 
longus.  Boof,  skin,  superficial,  deep  and  cribriform  fascia. 
Floor,  iliacus,  psoas,  pectineus,  adductor  longus,  and  adductor 
brevis.  Ajjex,  crossing  of  sartorius  and  adductor  longus.  Length, 
from  base  to  apex,  four  inches. 

Hunter'' s  canal.  A  triangular,  aponeurotic  canal,  correspond- 
ing to  the  middle  third  of  the  thigh.  Anterior,  sartorius.  Mx- 
ternal,  vastus  internus.  Internal,  adductor  magnus.  This  canal 
incloses  the  femoral  artery,  vein,  and  long  saphenous  nerve. 

Collateral  circulation.  Common  femoral.  Gluteal,  circumflex 
iliac  and  ilio-lumbar  with  the  external  circumflex.  Obturator 
and  sciatic  with  internal  circumflex.  At  apex  of  Scarpa'' s  triangle. 
Comes  nervi  ischiadici  with  arteries  of  the  ham.  Perforating 
branches  of  profunda  femoris  and  anastomotica  magna  with 
articular  arteries  of  popliteal,  and  recurrent  of  the  anterior 
tibial. 

Popliteal.  A  continuation  of  the  femoral,  from  the  opening 
in  the  adductor  magnus.  It  passes  obliquely  downwards  and 
outwards  behind  the  knee-joint,  and  ends  at  the  lower  border  of 
the  popUteus  muscle.  The  artery,  throughout  its  extent,  lies  in 
the  popliteal  space.  It  lies  deep,  and  is  crossed  by  the  internal 
popliteal  nerve  and  the  popliteal  vein.  The  nerve  lies  super- 
ficial to  the  vein,  which,  in  turn,  is  superficial  to  the  artery. 

lAne.  Middle  of  ham  ;  the  vessel  runs  along  the  external 
border  of  the  semi-membranous  tendon. 

Belations.  Upper  third,  from  outer  side,  1.  Nerve.  2.  Vein. 
3.  Artery.  ioiceri/iM'c^  from  outer  side,  1.  Artery.  2.  Vein.  3. 
Kerve.     Branches,  4  articulars,  2  muscular,  azygos,  cutaneous. 


LIGATION    OF    ARTERIES. 


275 


Operation.  Rarely  undertaken.  Patient  supine,  leg  extended. 
Incision  four  inches,  in  the  line  of  the  artery.  Great  care  must 
be  exercised  in  separating  the  vein  from  the  artery.  In  opera- 
ting on  the  lower  third,  avoid  the  external  saphenous  vein. 

Collateral  circulation.  Articulars  with  anastomotica  magna 
and  external  circumflex.  Superior  muscular  branches  with 
terminals  of  profund. 


The  arrow  marks  the  tendinous  arch  between  the  flexor  longus  pollicis  and 
flexer  longus  digitorum,  beneath  which  the  posterior  tibial  artery  lies. 


Posterior  tibial.  From  the  popliteal,  at  the  lower  border  of 
the  popliteus  muscle  (corresponding  to  the  level  of  the  lower 
part  of  the  tubercle  of  the  tibia),  to  a  point  a  finger's  breadth 
behind  the  external  malleolus.     The  vessel  is  covered  by  skin 


276  ESSENTIALS    OF    SURGERY. 

and  fascia,  gastrocnemius,  soleus,  plantaris,  and  a  tendinous 
arch  extending  between  the  flexor  longus  digitorum  and  the 
flexor  longus  poUicis.  The  posterior  tibial  nerve  crosses  the 
artery  in  its  upper  portion,  from  the  inner  to  the  outer  side. 
The  artery  rests  upon  the  tibialis  posticus,  the  flexor  longus  digi- 
torum, and  the  lower  end  of  the  tibia. 

Line  of  incision.  Upper  third,  along  inner  border  of  tibia. 
Middle  third,  one-half  inch  from  inner  border  of  tibia.  Lower 
third  (ankle),  midway  between  internal  malleolus  and  tendo 
Achillis.  Pass  the  ligature  from  the  nerve.  Incision  in  upper 
and  middle  third  four  inches.  The  artery  in  its  upper  third  lies 
very  deep,  and  is  secured  by  separating  the  soleus  from  the  tibia 
working  outwards  in  the  muscular  interspace  between  the  soleus 
and  the  flexor  longus  digitorum. 

Behind  malleolus.  Incision  two  inches  long,  a  finger's  breadth 
behind^  the  internal  malleolus,  convex  backward.  Artery  lies 
beneath  the  deep  fascia,  delations.  Anterior.  Tendon  of  flexor 
longus  digitorum.  Posterior.  Nerve  and  tendon  of  flexor 
longus  pollicis.  Branches.  Kutrient,  peroneal,  muscular,  com- 
municating calcanean. 

Anterior  tibial.  Commences  at  the  lower  border  of  the  pop- 
liteus  muscle,  passes  forwards  between  the  two  heads  of  the 
tibialis  posticus,  through  an  opening  above  the  interosseous  mem- 
brane to  the  deep  part  of  the  front  of  the  leg,  descends  on  the 
anterior  surface  of  the  interosseous  membrane  (upper  two-thirds), 
and  tibia  (lower  one-third),  to  the  middle  of  the  bend  of  the 
ankle  joint,  where  it  is  more  superficial  and  becomes  the  dorsaUs 
pedis. 

Line.  From  a  point  midway  between  the  tubercle  of  tibia 
and  head  of  fibula  to  the  centre  of  the  interraalleolar  space. 

The  ligature  is  passed  from  the  outer  side. 

Eelations.  Upper  third.  Between  the  tibialis  anticus  and  ex- 
tensor longus  digitorum.  Nerve  to  outer  side.  Middle  third. 
Between  tibiaUs  anticus  and  extensor  proprius  pollicis.  Nerve 
in  front  or  to  inner  side.  Lower  third.  Between  extensor  pro- 
Ijrius  poUicis  and  extensor  longus  digitorum,  or  frequently  as  in 
middle  third.     Nerve  to  outer  side. 


LIGATION    OF    ARTERIES.  277 

Operation.  Upper  third.  Patient  supine.  Knee  flexed,  sole 
of  foot  resting  on  table.  Incision  three  inches.  After  opening 
deep  fascia  search  with  handle  of  knife  for  interspace  between 
tibialis  anticus  and  extensor  communis  digitorum  ;  artery  found 
between  them  resting  on  interosseous  membrane.  IKerve  to 
outer  side.  Pass  thread  from  without.  The  interspace  may  be 
defined  by  extending  the  toes  and  the  foot  in  turn,  thus  putting 
each  muscle  upon  the  stretch.  Middle  and  lower  third,  as  for 
upper  third,  except  for  the  changed  relations.  Branches.  Ante- 
rior tibial  recurrent,  muscular,  internal  malleolar,  external  mal- 
leolar. 

Dorsalis  pedis.  The  continuation  of  the  anterior  tibial.  Ex- 
tends from  the  centre  of  the  instep  beneath  the  annual  ligament, 
to  the  base  of  the  metatarsal  bone  of  the  great  toe,  where  it 
divides  into  the  communicating  and  dorsalis  hallucis.  Its  course 
is  from  the  centre  of  the  instep,  to  the  space  between  the  first 
two  toes. 

It  is  covered  simply  by  skin  and  fascia,  and  crossed  near  its 
point  of  bifurcation  by  the  innermost  tendon  of  the  extensor 
brevis  digitorum,  which  serves  as  a  guide  in  its  ligation. 

The  ligature  is  passed  from  without  inwards.  The  artery  is 
found  between  the  tendon  of  the  extensor  proprius  poUicis  and 
the  inner  tendon  of  the  extensor  brevis  digitorum.  Anterior 
tibial  nerve  lies  to  the  outer  side.     Incision  one  inch  long. 

External  plantar  artery^  a  terminal  branch  of  the  posterior 
tibial.  Passes  from  the  lower  part  of  the  internal  lateral  liga- 
ment posterior  to  the  internal  malleolus,  forward  and  outward, 
taking  a  slightly  arched  course  with  the  convexity  outward,  to 
the  base  of  the  fourth  metatarsal  space.  This  forms  its  superfi- 
cial part,  and  is  covered  by  the  fasciae  and  first  layers  of  the  foot 
muscles.  From  this  point  it  winds  round  the  outer  border  of 
the  accessorius,  and  passes  forward  and  inward  to  the  posterior 
part  of  first  interosseous  space,  forming  the  plantar  arch,  and 
lying  upon  the  interos8ei,  and  bases  of  the  metatarsal  bones. 


278  ESSENTIALS    OF    SURGERY. 


EXCISION  OF  JOINTS. 

What  is  the  distinction  between  excision  and  resection? 

Excision  means  the  removal  of  the  joint  surfaces  of  bone.  Re- 
section means  the  removal  of  the  shaft  of  a  long  bone. 

What  is  arthrectomy? 

The  removal,  by  dissection,  of  the  diseased  synovial  mem- 
brane of  a  joint,  without  interfering  with  the  bone. 

What  conditions  may  require  excision? 

Injury.  Instance,  compound  luxation,  compound  commi- 
nuted fracture. 

Disease.     Instance,  tubercular  synovitis  or  arthritis. 
Deformity.     Instance,  anchylosis  in  bad  position. 

What  conditions  contraindicate  excision  ? 

Malignant  growth.  Acute  disease.  Extensive  involvement  of 
bone  or  soft  parts.  Extremes  of  age.  Marked  amyloid  degene- 
ration. 

What  precautions  are  observed  in  excising  a  joint  ? 

The  incision  should  be  free,  and  in  the  long  axis  of  the  limb. 
Spare  the  bone,  substituting  the  gouge  or  curette  for  the  saw 
whenever  practicable.  Save  the  periosteum  and  the  capsule  of 
the  joint,  if  they  are  healthy.  Secure  absolute  immobility  by 
splinting. 

How  do  you  dress  an  excision  ? 

Bone  drainage-tubes,  iodoform,  protective,  bichloride  gauze, 
bichloride  cotton,  plaster  bandage.  Where  a  movable  joint  is 
desired,  do  not  apply  the  fixed  dressing. 

Shoulder-joint.  Position  of  patient,  on  his  back,  the  aJBTected 
shoulder  projecting  beyond  the  side  of  the  operating  table. 

Incision  four  inches  in  length  from  a  point  slightly  above  and 
to  the  outer  side  of  the  coracoid  process,  downward  and  some- 
what outward,  external  to  the  cephalic  vein.  The  long  head  of 
the  biceps  should  be  freed  by  a  longitudinal  cut.  The  humerus  is 
rotated  outwards,  and  the  periosteum  and  tendon  of  the  subscapu- 


EXCISION    OF    JOINTS, 


279 


Fig.  63. 


laris  separated  by  the  elevator.  The  humerus  is  then  rotated  in- 
wards, and  the  periosteum  and  muscular  attachments  to  the 
greater  tuberosity  are  separated.  Finally  the  humerus  is  forced 
directly  upward,  the  ^posterior  part  of  the  capsule  is  freed  by  the 
periosteal  elevator  (avoid  the  posterior  circumflex  ar- 
tery and  circumflex  nerve),  the  bone  is  sawed  through 
the  surgical  neck.  A  posterior  opening  is  made  for 
drainage,  and  the  wound  dressed  with  a  pad  in  the 
axilla  and  the  arm  to  the  side.  Motion  as  soon  as 
possible. 

Elbow-joint.  Incision  three  to  four  inches  long, 
slightly  internal  to  the  middle  line  of  the  olecranon 
and  humerus,  with  its  central  point  opposite  the  top 
of  the  olecranon.  Clear  the  olecranon  of  periosteum 
and  soft  parts  with  the  elevator  (carefully  guarding 
the  ulnar  nerve)  and  saw  off;  now  forcibly  flex  the  hu- 
merus and  clear  it  in  the  same  way,  sawing  from 
before  backward,  just  above  the  trochlear  surface. 
Finally  clear  the  ends  of  the  radius  and  ulnar,  and 
remove  their  articulating  extremities  just  below  the 
sigmoid  notch  and  capitellum.  Stri})  the  hones  sitb- 
'periosteally . 


m 
m 

m 

f 

i 
M 


Wrist-joint.  Two  incisions.  The  radial  incision^ 
planned  to  avoid  the  artery,  commences  at  the  level 
of  the  styloid  process,  on  the  middle  of  the  dorsal 
aspect  of  the  radius,  passes  downward,  parallel  to 
the  tendon  of  the  extensor  secundi  internodii  poUi- 
cis,  till  it  reaches  the  line  of  the  border  of  the  second 
metacarpal  bone  ;  it  is  then  carried  longitudinally 
downward  for  half  the  length  of  the  bone. 

The  ulnar  incAsion.   From  a  point  two  inches  above 
the  lower  extremity  of  the  ulna  and  just  anterior 
to  the  inner  edge  of  the  bone,  downward  as  far  as       Metacar- 
tho  middle  of  the  fifth  metacarpal  bone. 

Hip-joint.  Anterir/r  incAsion,  three  inches  long,  running  down- 
ward and  slrglitly  outward,  from  half  an  incli  below  and  external 
to  the  anterior  superior  spinous  process  of  the  ilium. 


280 


ESSENTIALS    OF    SURGERY. 


Posterior  incision.     Begin  midway  between  anterior  superior 
spine   of  ilium  and  top  of  troclianter ;   sweep  backward  and 

downward  behind  posterior  mar- 
^^S*  64.  gjj^  Qf  ^i^Q  trochanter  for  about 

three  inches,  keeping  about  an 
inch  back  of  the  edge  of  the 
bone.  Do  not  force  the  head  of 
the  bone  from  the  wound^  but  di- 
vide in  situ  by  a  narrow  saw ; 
remove  subsequently  with  se- 
questrum forceps.  Curette  and 
gouge  away  all  diseased  portions 
of  the  acetabulum,  remove  dis- 
eased synovia  or  capsule,  wash 
out  with  zinc  chloride,  dry  with 
bichloride  sponges,  dust  with 
iodoform.  Dress  antiseptically 
and  apply  a  double  Thomas's 
splint. 

Knee-joint.  Incision  from  the 
outer  and  posterior  border  of  the 
internal  condyle,  to  a  corre- 
sponding point  on  the  external 
condyle,  curving  downward  suf- 
ficiently to  pass  midway  between 
the  patella  and  the  tuberosity 
of  the  tibia.  Dissect  up  the  an- 
terior flap  containing  the  patella, 
flex  the  joint,  divide  the  lateral 
and  crucial  ligaments,  clear  the 
end  of  the  femur  with  the  finger, 
saw  at  right  angles  to  its  long 
axis  near  the  upper  margin  of 
Butcher's  saw.  the  cartilaginous  surface.     Use 

Butcher's  saw,  cutting  from  be^ 
hind  forward.  Clear  the  end  of  the  tibia,  and  remove  its  articu- 
lating extremity.     Eemove  by  the  gouge  or  curette  all  diseased 


EXCISION    OF    JOINTS.  281 

tissue.  Suture  the  bone  together  with  thick  cat-gut  or  silver 
wire,  provide  for  dramage,  and  close.  Absolute  fixation,  plaster 
bandages  if  the  wound  remains  aseptic. 

Ankle-joint.  Yery  rarely  performed.  Every  effort  should 
be  made  to  preserve  the  periosteum.  Two  incisions  are  made. 
The  fibular  hegms  two-and-a-half  inches  above  the  tip  of  the  ex- 
ternal malleolus,  passes  downward  along  its  posterior  border, 
around  its  tip,  and  upwards  along  the  anterior  border  for  an  inch 
(hook-shaped).  The  tibial  forms  a  semicircle  around  and  just 
below  the  internal  malleolus,  from  the  middle  of  which  a  third 
cut  runs  directly  upwards  over  the  malleolus  for  two  inches  (an- 
chor-shaped). The  periosteum  is  first  raised  from  the  fibula, 
when  the  bone  is  sawed  and  removed.  I^ext,  the  articulating 
end  of  the  tibia  is  removed  ;  finally  the  astragalus  is  sawn 
through.  If  the  elevator  is  carefully  used,  the  tendons  and  their 
sheaths  will  not  be  daraaored. 


282 


ESSENTIALS    OF    SURGERY, 


AMPUTATIONS. 

Under  what  circumstances  is  amputation  required  ? 

1.  Avulsion  of  a  limb.  2.  Mortification.  3.  Compound  luxa- 
tions and  fractures,  if  seriously  complicated.  4.  Extensively 
lacerated  and  contused  wounds.  5.  Diseases  of  bones  and  joints. 
6.  Lesions  or  diseases  of  arteries.  7.  Morbid  growths.  8.  De- 
formity. 

What  instruments  are  required  in  amputation  ? 

Tourniquets,  knives,  saws,  retractors,  tenacula,  artery  forceps, 
haemostatic  forceps,  bone-nippers,  scissors,  needles,  and  sutures. 

Describe  the  methods  of  operating^. 

1.  Circular.  The  skin  is  drawn  upward  and  divided  by  a  cir- 
cular sweep  of  the  knife,  passing  entirely  around  the  limb,  and 


Amputation  by  the  circular  method. 

dividing  everything  down  to  the  muscles  ;  this  skin  cuff  is  further 
dissected  up  till  its  length  is  a  little  greater  than  half  the  dia- 
meter of  the  limb  ;  it  is  then  retracted,  the  muscles  are  separated 
down  to  the  bone  by  a  second  circular  incision,  and  the  latter  is 
sawed  through. 

2.  Flap.  There  maj'^  be  one  or  two  flaps  ;  these  may  be  ante- 
rior, posterior,  lateral,  square  or  oval ;  they  may  be  cut  by  trans- 
fixion, or  from  without,  and  may  include  all  the  soft  parts  (mus- 


AMPUTATIONS 


283 


culo-cutaneous),  or  simply  the  sMn  and  superficial  fascia  (cuta- 
neous). 

Describe  the  methods  of  shaping  the  flap. 

Modified  drmlar.     Two  short,  curved,  skin-flaps  are  cut,  and 
the  notched  skin  cuff  is  dissected  up  as  in  the  circular  method. 


Fig. 


Fig.  67. 


Formation  of  flaps  by  transfixion. 


Teale's  amputation. 


Oval  and  elliptical  The  oval  method  is  practically  a  circular 
incision,  with  the  cuff  sUt  at  one  side,  and  its  angles  rounded 
off 

In  the  elliptical  method  the  incision  forms  a  perfect  ellipse  ;  the 
flap  is  folded  upon  itself  and  sutured,  making  a  curved  cica- 
trix. 

Teale's  method.  Kectangular  flaps,  each  equal  in  breadth  ;  one 
has  a  length  of  half  the  circumference  of  the  Hmb,  the  other  (con- 
taining the  bloodvessels)  is  only  quarter  as  long. 

How  are  amputations  classified  in  regard  to  the  time  of  ope- 
rating ? 

Primary,  before  the  occurrence  of  inflammatory  fever.  Inter- 
mediate, during  acute  inflammatory  fever.  Secondary,  after  sup- 
puration has  been  established. 

What  period  is  most  favorable  for  amputation  1 

Ikifore  the  occurrence  of  inflammatory  fever.  If  the  time  for 
primary  amputation  has  passed,  wait  for  the  secondary  period. 


284 


ESSENTIALS    OF    SUKGERY. 


What  sequelae  may  occur  after  amputation? 

Hemorrhage,  muscular  spasm,  pain,  inflammation,  osteomye- 
litis, protrusion  of  bone. 


Amputations  of  the  Foot. 


Lisfranc's  amputation. 


Fig.  68. 


Tarso-metatarsal  disarticulation ;  be- 
tween the  metatarsal  bones  and  the 
three  cuneiforms  and  cuboid. 

Incision.  From  the  base  of  the  first 
to  the  base  of  the  fifth  metatarsal  bone 
across  the  dorsum  of  the  foot,  with 
a  marked  convex  curve  downward. 
Forcibly  extend  and  disarticulate, 
bearing  in  mind  the  backward  pro- 
jection of  the  second  metatarsal  bone. 
Cut  a  long  plantar  flap. 

Arteries.  Dorsalis  pedis  and  plan- 
tar arches. 

Hey's  amputation.  The  same  as 
Lisfranc's,  except  that  the  projecting 
internal  cuneiform  bone  is  sawed 
through. 

Chopart's  amputation.  Intertar- 
sal  disarticulation,  between  the  as- 
tragalo-scaphoid,  and  calcaneo-cu- 
boid  joint. 

Incision.     From  a  point  midway 
between  the  tuberosity  of  the  fifth 
metatarsal  bone  and   the   external 
malleolus,  a  curved  dorsal  incision  is  made  to  a  point  one-half 
inch  behind  the  tubercle  of  the  scaphoid.     Extend  the  foot,  dis- 
articulate, and  cut  a  long  plantar  flap. 

Pirogoff's    amputation.      Through   the  ankle-joint  and    os 
calcis. 

Incision.,   from  the  tip  of  the  external  malleolus,  across  the 
under  surface  of  the  heel,  to  a  point  half  an  inch  below  and 


li.  Lisfranc's  operation.  H. 
The  extremity  of  the  internal 
cuneiform  removed  by  Hey's 
operation.  C.  Chopart's  ope- 
ration. 


AMPUTATIONS.  285 

behind  the  internal  malleolus.  Incline  this  cut  well  forward. 
Forcibly  extend  the  foot  and  unite  the  ends  of  the  first  incision 
by  a  deep  cut  passing  directly  across  the  dorsum.  Open  the 
joint,  draw  the  foot  forward,  place  a  narrow  saw  behind  the 
astragalus  and  saw  the  os  calcis  through  in  the  line  of  the  first 
skin  incision.  Saw  off  the  ends  of  the  tibia  and  fibula,  bring 
the  heel  flap  up  till  the  sawn  bone  surfaces  are  in  contact,  unite 
them  with  heavy  catgut,  and  suture  the  wound. 

Syme's  amputation.     Through  the  ankle-joint. 

Incision.  Inclining  hackivard  from  tip  of  external  malleolus, 
beneath  the  heel,  to  a  point  half  an  inch  below  and  behind  the 
internal  malleolus.  Dissect  the  flap  from  the  os  calcis  cutting 
towards  the  hone.  Unite  the  ends  of  the  first  incision  by  a  trans- 
verse cut  across  the  front  of  the  ankle-joint,  disarticulate,  saw 
off  the  articular  extremities  of  the  tibia  and  fibula,  and  bring 
the  flaps  together. 

Amputations  of  the  Leg. 

Lower  third  of  the  leg.  By  the  circular,  modified  circular, 
bilateral  tegumentary  flap,  Teale's  method.  The  fibula  should 
be  divided  first.  Arteries.  Anterior  and  posterior  tibial,  pero- 
neal, and  muscular. 

Middle  and  upper  third  of  the  leg.  By  a  long  anterior  tegu- 
mentary flap  half  the  circumference  of  the  limb  in  breadth  and 
a  little  more  in  length.  By  short  antero-posterior  flaps.  By 
lateral  musculo-tegumentary  flaps  (Sedillot's).  The  projecting 
sharp  edge  of  the  tibia  should  be  covered  with  a  flap  of  perios- 
teum to  prevent  perforation  of  the  anterior  flap. 

Lateral  double  flap  method  (Sedillot's).  A  long  external 
flap  is  formed  by  transfixion,  and  united  to  the  short  internal 
flap  formed  by  the  calf  muscles. 

Lateral  tegumentary  flaps  may  be  formed  cutting  from  with- 
out inward. 

Point  of  election  in  leg  amputation.  Two  inches  IjcIow  the 
tuberosity  of  the  tibia. 


286  ESSENTIALS    OF    SURGERY. 


Amputations  at  the  Knee-Joint. 

"Where  indicated  by  injury  or  disease  this  is  one  of  the  most 
successful  of  all  leg  amputations,  and  leaves  a  far  more  service- 
able stump  than  amputation  in  the  continuity  of  the  limb. 

Lateral  flap  operation.  Commence  the  incision  in  the  middle 
line  an  inch  below  the  tubercle  of  the  tibia,  form  a  flap  convex 
downward,  carrying  the  point  of  the  knife  to  the  centre  of  the 
posterior  surface,  when  it  is  continued  directly  upward  to  the 
centre  of  the  articulation.  The  second  incision  begins  at  the 
same  point  as  the  flrst,  and  pursues  the  same  course  on  the  op- 
posite side  of  the  leg  to  the  posterior  median  line.  The  anterior 
incisions  should  incline  forward  to  allow  sufficient  material  for 
covering  the  condyles.  The  internal  flap  should  have  additional 
fulness.  The  patella  and  semilunar  cartilages  are  allowed  to 
remain. 

Long  anterior  flap.  Incision  from  the  lower  extremity  of  the 
inner  condyle  downward  for  three  inches,  then  directly  across 
the  tibia  and  upward  to  the  external  condyle.  Disarticulate  and 
cut  a  short  posterior  flap. 

Amputation  through  the  femoral  condyles  (Garden's).  In- 
cision, from  the  upper  border  of  the  inner,  to  the  upper  border 
of  the  external  condyle,  carried  downward  and  across  the  front 
of  the  leg  just  below  the  insertion  of  the  ligamentum  patellae. 
Short  posterior  flap  by  transfixion.  Condyles  sawed  across. 
The  patella  is  not  left  in  the  anterior  flap. 

Gritti's  modification.  Consists  in  sawing  off  the  articular  sur- 
face of  the  patella,  turning  it  backward,  and  suturing  it  to  the 
divided  femur. 


Amputations  of  the  Thigh. 

Antero-posterior  musculo-tegumentary  flaps.    Anterior  cut 
from  without  inwards,  about  four  inches  lony;,  and  somewhat 


AMPUTATIONS.  287 

square.  Posterior  flap  about  the  same  length  to  allow  for  re- 
traction, cut  by  transfixion.  The  posterior  muscles  of  the  thigh 
always  retract  more  than  the  anterior  group. 

Lateral  flap.    Teale's  method  or  modified  circular  operation 
may  also  be  done  on  the  thigh. 


Hip-Joint  Amputation.  . 

Hemorrhage  controlled  by  abdominal  tourniquet,  digital  pres- 
sure on  the  femoral,  and  Esmarch's  tube  applied  in  the  form  of 
a  spica  of  the  groin. 

Long  anterior  and  short  posterior  flaps.  Enter  the  knife  at 
a  point  midway  between  the  anterior  superior  spinous  process 
of  the  ilium  and  the  tip  of  the  trochanter,  push  it  directly  across 
the  capsule  of  the  joint,  grazing  the  head  of  the  bone,  till  it  ap- 
pears on  the  inner  side  of  the  thigh  just  in  front  of  the  tuber 
ischii ;  cut  directly  downwards  for  six  inches,  let  the  femoral 
artery  be  seized  by  the  fingers  of  an  assistant,  then  complete  the 
anterior  flap  by  cutting  outward.  Turn  the  flap  up,  clear  the  cap- 
sule, forcibly  extend  the  femur,  and,  placing  the  knife  behind 
the  trochanter,  form  a  somewhat  shorter  posterior  flap.  First 
secure  the  gluteal  and  sciatic  vessels,  then  the  femoral  artery 
and  vein.  The  flaps  may  be  cut  from  without  inwards,  securing 
the  vessels  as  cut. 

Vertical  and  circular  method.  A  vertical  incision  is  made, 
from  a  little  above  the  tip  of  the  trochanter  for  five  inches  in  the 
long  axis  of  the  femur.  Through  the  incision  disarticulation  is 
effected,  and  by  means  of  the  elevator  and  knife  the  soft  parts 
are  separated  from  the  bone.  At  the  lower  extremity  of  the 
vertical  incision,  skin,  fascia,  and  muscles  are  divided  by  a 
circular  sweep  of  the  knife  around  the  thigh,  and  the  entire 
femur,  together  with  the  soft  parts  below  the  circular  cut,  is 
removed.  This  operation  is  tedious,  but  far  more  safe  than  the 
double  flap  method. 


288  ESSENTIALS    OF    SURGERY 


Amputation  of  the  Hand. 

Phalanges.  The  pahuar  flexure  is  the  guide  to  the  joint  sur- 
face. Flex  the  joint,  open  it  by  a  shghtly  convex  dorsal  in- 
cision a  little  below  its  most  prominent  part,  and  cut  a  long 
palmar  flap.  The  digital  arteries  can  usually  be  secured  by  the 
skin  suture.  The  proximal  phalanx  of  the  middle  and  ring 
fingers  should  not  be  saved. 

Metacarpo-phalaugeal.  Oval  metliod  (en  raquette).  The  point 
of  the  knife  is  entered  in  the  mid  dorsal  line,  a  little  above  the 
knuckle,  carried  first  downward,  then  around  the  side  of  the  fin- 
ger, across  its  web  and  palmar  surface,  and  back  to  the  point  of 
starting. 

Any  of  the  bones  of  the  hand  may  be  amputated  through  their 
continuity  by  either  the  double  flap,  or  the  oval  method. 

Wrist-joint.  Incision,  convex  downward,  from  styloid  process 
of  radius  to  corresponding  process  of  ulna.  Dissect  up  the  flap, 
divide  tendons,  disarticulate,  and  cut  a  palmar  flap  from  within, 
guarding  against  the  knife  catching  on  the  pisiform  bone. 


Amputations  of  the  Arm  and  Forearm. 

Forearm.  Modified  circular,  or  antero-posterior  flaps.  Teale's 
method. 

Arteries.  Anterior  and  posterior  interosseous,  radial  and 
ulnar. 

Elbow-joint.  The  line  of  articulation  is  oblique,  from  with- 
out inward  and  downward,  hence  there  will  not  be  enough  flap 
to  cover  the  internal  condyle  if  the  knife  is  carried  directly 
across  the  arm. 

Long  anterior  and  short  posterior  flap.  Flex  and  supinate 
the  forearm,  raise  the  soft  parts  from  the  bone,  enter  the  knife 
an  inch  below  the  internal  condyle,  and  push  it  across  the  limb 
close  to  the  ulna,  till  it  appears  an  inch  and  a  half  below  the 


AMPUTATIONS.  289 

external  condyle.  Make  a  three-inch  flap,  bringing  the  knife 
out  sharply  at  the  finish.  Draw  the  skin  well  up  and  unite  the 
two  extremities  of  the  incision  by  a  semilunar  dorsal  cut.  Dis- 
articulate, either  dividing  the  triceps,  or  sawing  off  the  ole- 
cranon. 

Circular  method.  The  incision  is  made  three  to  four  inches 
below  the  joint. 

Arm.     Circular.     Flap.    Any  of  the  methods. 

Shoulder- Jo  int. 

Oval  method.  (Larrey's.)  Forming  lateral  musculo-tegument- 
ary  flaps.  Enter  the  point  of  the  knife  to  the  bone  just  below 
the  acromion  process,  and  make  an  incision  downward  in  the 
long  axis  of  the  arm  for  about  two  inches.  From  the  end  of  the 
incision  two  curved  incisions  are  carried  to  the  anterior  and 
posterior  axillary  folds,  respectively.  These  flaps  are  dissected 
up,  and  disarticulation  is  effected  by  rotating  the  humerus  out- 
ward, and  dividing  first  the  subscapularis,  then  the  long  head  of 
the  biceps  and  capsular  ligament,  then  rotating  the  humerus 
inward  and  dividing  the  insertions  of  the  supra-  and  infra-spi- 
nator  and  teres  minor  muscles.  The  knife  is  now  placed  behind 
the  bone,  and  the  two  curved  incisions  are  joined  by  a  trans- 
verse cut,  severing  the  axillary  artery,  which  is  controlled  by 
the  thumb  of  an  assistant  before  it  is  divided.  Hemorrhage  is 
checked  by  pressure  on  the  subclavian,  Esmarch's  tube,  and 
seizure  of  the  artery  in  the  flap  before  it  is  cut.  Arteries.  An- 
terior and  posterior  circumflex,  supra-scapular,  brachial. 

Single  flap  method.  (Dupuytren's.)  A  long  external  flap  is  cut 
from  the  deltoid  muscle,  either  by  transfixing,  or  from  without 
in. 


Id 


:290  ESSENTIALS    OF    SURGERY. 

BANDAGING. 

The  Roller  Bandage. 

Describe  the  roller  bandage. 

A  strip  of  unbleached  muslin,  from  half  an  inch  to  three  inches 
in  width,  and  from  three  to  twelve  yards  in  length.  It  may  be 
made  of  calico,  linen,  or  gauze.  It  is  tightly  rolled  in  the  form 
of  a  cylinder ;  the  rolling  may  be  from  each  end,  forming  the 
double-headed  bandage. 

Name  the  parts  of  a  roller  bandage. 

The  initial  and  terminal  extremities,  the  upper  and  lower  bor- 
ders, the  internal  and  external  surfaces,  and  the  body  of  the 
roller. 

How  do  yon  apply  a  roller  bandage? 

Fix.  The  body  of  the  roller  being  held  in  the  right  hand,  the 
external  surface  of  the  initial  extremity  is  applied  to  the  surface, 


Method  of  applying  the  spiral  reversed  bandage. 

fixed  by  the  thumb  of  the  left  hand  till  it  is  caught  by  the  band- 
age carried  around  the  limb,  when  it  is  further  held  in  place  by 
a  repeated  circular  turn.  The  following  turns  can  be  made  to 
overlap  this  circular,  covering  in  from  a  half  to  three-fourths  of 
its  surface.  If  the  part  is  conical,  the  overlapping  turns  may  be 
made  to  lie  smoothly  by  the  reverse. 

The  circular  turns  are  those  which  pass  around  the  part,  one 
passing  directly  over  the  other. 

The  spiral  turns  are  those  which  pass  up  the  limb,  each  one 
overlapping  the  other. 


BANDAGING. 


291 


Fig.  70. 


The  oblique  turns  are  those  in  which  the  bandage  passes  up 
the  limb  witliout  overlapping,  leaving  space  be- 
tween each  turn. 

Becurrent  turns  are  those  in  which  the  bandage 
is  caught,  passed  to  and  fro,  across  the  end  of  a 
stump  for  instance,  and  the  loops  held  at  the 
sides  by  circular  turns. 

Spica  and  figure-of-eight  turns  are  those  in  which 
the  bandage  forms  by  oblique  turns  two  loops  in 
the  form  of  an  eight.  By  overlapping,  the  crossings 
of  these  loops  form  a  series  of  angles  or  spicas. 

Describe  the  reverse. 

Consists  in  folding  the  bandage  over,  so  that 
the  surface  in  contact  with  the  skin  is  changed 
with  each  reversed  turn.  This  is  accomplished 
by  relaxing  all  tension  on  the  roller,  carrying  the 
right  hand,  holding  the  body  of  the  roller,  from 
supination  to  pronation,  passing  the  body  of  the 
roller  to  the  left  hand  beneath  the  hmb,  and 
makins:  firm  traction. 


Oblique  band- 
age. 


For  what  purposes  is  the  roller  applied  ? 

The  general  indications  for  all  roller  bandages  are  to  retain 
splints  and  dressings,  and  to  make  pressure. 

Spiral  of  one  finger.  Length,  one-and-a-half  yards  ;  width, 
three-fourths  of  an  inch.  Fix  by  a  circular  turn  at  the  wrist 
once  repeated.  Carry  the  bandage  down  over  the  dorsum  of  the 
hand,  and  by  an  oblique  turn  to  the  extremity  of  the  finger,  which 
is  then  covered  in  by  spiral  or  reversed  turns  as  required.  Com- 
plete the  bandage  by  carrying  it  up  to  the  wrist,  over  the  back 
of  the  hand,  and  making  one  circular  turn. 

Spiral  of  four  fingers  (gauntlet).  Length,  five  yards  ;  breadth, 
one  inch.  Cover  in  each  finger  precisely  as  above,  beginning 
with  the  little  finger  of  the  left  hand,  the  index-finger  of  the 
right.  As  each  finger  is  finished,  the  bandage  is  carried  to  the 
wrist,  around,  and  then  down  to  the  next  finger.  The  thumb 
may  be  included  in  this  bandage  if  necessary. 


292 


ESSENTIALS    OF    SURGERY, 


Spica  of  the  thumb.  Length,  three  yards ;  width,  three-quar- 
ters of  au  inch.     May  be  ascending  or  descending.     Ascending. 


Fig.  71. 


Fig.  72. 


Fig.  73. 


Gauntlet,  also  taking  In 
the  thumb. 


Spica  of  thumb. 


Spiral  of  one  finger. 


Fix  at  the  wrist.  Pass  to  the  metacarpo-phalangeal  articula- 
tion, and  make  a  circular.  Pass  to  the  wrist  again,  and  alter- 
nate the  wrist  and  thumb  turns  so  that  the  line  of  crossing  is 
over  the  dorsum  of  the  thumb.  Overlap  two-thirds  from  below 
upward.  The  descending  spica  has  the  same  turns,  but  over- 
laps from  above  downward. 

Demi-gauntlet.  Length,  three  yards ;  breadth,  one  inch.  Fix 
at  the  wrist,  pass  obliquely  across  the  back  of  the  hand  to  the 
index-finger  of  the  right  hand  the  little  finger  of  the  left ;  pass 
around  the  finger,  and  obliquely  back  to  the  wrist.  Make  a  cir- 
cular turn,  then  take  in  the  next  finger  in  a  similar  way  till  each 
one  is  encircled  by  a  loop. 

Spiral  reversed  of  upper  extremity.  Length,  twelve  yards  ; 
width,  one  and  one-half  inches.  Apply  with  hand  in  pronation. 
Fix  at  the  wrist.  Carry  across  the  back  of  the  hand  and  make 
a  circular  turn  about  the  fingers  at  the  level  of  the  distal  joint 
of  the  little  finger.  Run  up  the  hand  with  spiral  reversed,  or 
figure-of-eight  turns,  covering  in  the  metacarpal  bone  of  the 
thumb  by  means  of  the  latter.     Continue  up  the  forearm  with 


BANDAGING. 


293 


spiral  turns  till  they  cease  to  fit  closely  to  the  surface,  when  the 
reverses  must  be  made.  The  elbow  must  be  covered  in  by  a  fig- 
ure-of-eight. Do  not  make  the  line  of  reverses  (the  line  of  pres- 
sure) over  the  subcutaneous  portion  of  the  ulna.  Overlap  two- 
thirds. 

Spica  of  the  shoulder.  Length,  ten  yards  ;  width,  two-and- 
one-hali  inches.  Ascending  or  descending.  Ascending.  Fix  by  a 
circular  turn  about  the  arm  placed  as  high  as  possible.  Carry 
the  bandage,  overlapping  the  circular  turn  where  it  passes  over 
it,  across  the  chest  (right  side)  or  back  (left  side),  under  the  oppo- 
site axilla  and  back  to  the  point  of  starting.  It  is  now  carried 
around  the  arm,  overlapping  the  circular  turn,  and  making  a  spica 
directly  in  the  middle  line  of  the  shoulder  with  the  beginning  of 
the  body  turn.  This  is  repeated,  passing  upward  till  the  entire 
shoulder  is  covered  in.  The  descending  spica  is  applied  by  the 
same  turns,  but  runs  from  above  downward  till  it  reaches  the 
first  circular  turn. 

Velpeau.  Length,  fourteen  yards  ;  width,  two  and  one-half 
inches.  For  the  proper  application  of  this  bandage  the  arm 
must  be  placed  in  the  Yelpeau  position,  the  hand  of  the  in- 
jured side  resting  on  the  sound 
shoulder. 

Commence  over  the  scapula  of 
the  sound  side,  carry  the  roller 
over  the  injured  shoulder  to  the 
middle  of  the  outer  aspect  of  the 
upper  arm,  across  the  chest  (be- 
hind the  elbow)  to  the  axilla  of 
the  sound  side,  thence  to  the 
point  of  starting.  Repeat  this 
turn  to  fix,  then  make  a  circular 
turn  about  the  chest,  taking  in 
the  elbow  of  the  injured  side.  Re- 
peat these  turns,  first  shoulder, 
then  body,  overlapping  so  that 
the  shoulder  turns  reach  the  point 
of  the  elbow  when  the  body  turns  Velpeau. 


Fiff.  74. 


294 


ESSENTIALS    OF    SURGERY. 


take  in  the  wrist.  This  requires  overlapping  of  about  five-sixths 
for  the  vertical  turns,  one-third  for  the  horizontal.  Used  to  dress 
fractured  clavicle  or  scapula. 

Desault.    Requires  three  rollers. 

First  roller.  Length,  five  yards ;  width,  two-and-one-half 
inches.  It  fixes  a  wedge-shaped  pad,  base  up,  in  the  axilla. 
Four  spiral  turns  are  made,  encircling  the  thorax  and  pad,  the 
roller  is  then  carried  from  the  pad  obliquely  to  the  sound 
shoulder,  about  which  and  the  pad  it  is  made  to  form  a  series 
of  spica  turns. 


Fig.  75. 


Fig.  76. 


Desault.    First  roller. 


Desault,     Second  and  third  roller 
(the  second  is  here  applied  last). 


Second  roller.  Length,  seven  yards ;  width,  two-and-one- 
half  inches.  Presses  the  elbow  to  the  side,  and  forces  the 
head  of  the  humerus  outward.  It  consists  of  a  number  of 
circular  turns  embracing  the  arm  and  chest,  and  running  from 
the  head  of  the  humerus  to  the  elbow,  overlapping  one-half. 
The  upper  turns  are  applied  very  lightly,  as  they  descend  the 
tension  on  each  turn  is  increased. 

Third  roller.  Length,  seven  yards  ;  width,  two-and-one-half 
inches.     Presses  the  shoulder  upward  and  backward.     Begin  at 


BANDAGING.  295 

the  axilla  of  the  sound  side,  carry  the  roller  obliquely  across  the 
chest,  over  the  injured  shoulder,  down  the  back  of  the  humerus, 
around  the  elbow  of  the  injured  side,  across  the  chest  again  to 
the  point  of  starting ;  then  under  the  axilla  of  the  sound  side, 
obliquely  across  the  back,  over  the  injured  shoulder,  down  in 
front  of  the  humerus,  around  the  elbow,  across  the  back  to  the 
point  of  starting.  This  forms  two  triangles,  one  anterior  the 
other  posterior.  Axilla,  shoulder,  elbow,  first  in  front,  then  be- 
hind, represent  the  angles  of  the  triangles.  These  turns  may 
overlap  two-thirds,  or  may  exactly  overlie. 

Spiral  of  chest.  Length,  seven  yards ;  width,  three  inches. 
Circular  around  the  w'aist,  ascends  to  the  axilla  by  spiral  turns 
overlapping  one-half.  Keep  from  slipping  down  by  making  a 
recurrent  turn  across  one  shoulder,  pinning  to  the  circular  turns, 
bringing  the  bandage  back  over  the  other  shoulder,  and  securing 
it  to  the  circular  turns  in  front. 

Anterior  figure-of-eight  of  chest.  Length,  seven  yards ;  width, 
tw^o-and-one-half  inches.  Fix  by  a  circular  about  the  right  arm, 
then  carry  the  roller  over  the  shoulder,  across  the  chest,  around 
the  left  shoulder,  across  the  chest  again,  around  the  right 
shoulder,  across  the  chest,  and  so  continue  till  the  required 
number  of  turns  have  been  applied.  Over  the  sternum  the 
spicas  may  run  up,  overlapping  three-fourths. 

Posterior  figure-of-eight  of  chest.  Length,  seven  yards ; 
width,  two-and-one-half  inches.  Fix  the  roller  upon  the  upper 
part  of  the  left  arm,  carry  it  over  the  left  shoulder,  obliquely 
across  the  back  to  the  right  axilla,  around  the  right  shoulder, 
obliquely  across  the  back  to  the  left  axilla,  and  so  continue  till 
Uie  necessary  number  of  turns  are  applied. 

Spica  of  breast.    May  be  single  or  double. 

Single.  Length,  ten  yards  ;  width,  two-and-one-half  inches. 
Starting  from  the  scai)ula  of  the  affected  side,  carry  the  roller 
over  the  shoulder  of  the  sound  side;,  just  beneath  the  affected 
breast,  and  around  the  chest  to  the  point  of  starting ;  repeat 
this  turn,  then  make  a  circular  around  the  chest,  taking  in  the 
lower  border  of  the  mammary  gland  and  making  a  spica  or  cross 


296 


ESSENTIALS    OF    SURGERY 


Spica  of  breast  (double). 


with  the  oblique  turn.     Alternate  these  circular  and  oblique 

turns,   and   continue    them,   overlapping 

^ig-  77.  two-thirds,  till  the  gland  is  covered  in. 

The  spicas  or  crosses  should  all  be  in  the 

same  line. 

Double.     Lensjth,   fourteen  yards  (two 
bandages)  ;      width,       two-and-one-half 
inches.     This  is  made  up  of  two  oblique 
turns  to  each  circular.     Start  from  the  left 
scapula  and  make  a  repeated  oblique  turn, 
passing  over  the  right  shoulder  and  under 
the  left  breast  as  before  ;  then  carry  the 
roller  around  the  chest  as  though  to  make 
a  circular  turn,  till  it  passes  beneath  the 
right  breast,  when  it  is  carried  obliquely  upward  over  the  left 
shoulder  (passing  above  and  to  the  inner  side  of  the  left  breast) ; 
across  the  back,  and  a  circular  is  made,  just  taking  in  the  lower 
borders  of  the  glands  and  making  spicas  with  the  two  obliques. 
Spica  of  the  Foot.    Length,  five  yards  ;  width,  two-and-a-half 
inches.     Begin  by  a  circular  turn  about  the  ankle  ;  pass  over 
the  dorsum  of  the  foot  to  the  metacarpo-pha- 
Fig.  78.  langeal  articulation  ;  make  a  circular  and  a 

^       ^  spiral  turn,  overlapping  three-fourths,  then 

p — ^  carry  the  roller  over  the  dorsum  of  the  foot 

to  the  back  of  the  heel,  around  the  heel,  so 
that  the  lower  border  of  the  bandage  extends 
as  low  as  the  level  of  the  sole,  then  back 
to  the  dorsum  of  the  foot,  crossing  the  begin- 
ning of  the  heel  turn  exactly  in  the  middle 
line  as  it  overlaps  the  spiral  turn  ;  this  forms 
the  first  spica.  Again  pass  around  the  sole  of 
the  foot,  across  the  dorsum  of  the  foot  overlapping  three-quarters, 
around  the  heel,  and  back  across  the  foot,  making  the  second 
spica.  So  continue  till  the  foot  is  covered  in.  Each  turn  of  the 
bandage,  after  the  spica  is  begun,  must  be  parallel  to  its  pre- 
decessors throughout  its  whole  extent,  and  must  overlap  to  the 
same  degree. 


Spica  of  the  foot. 


BANDAGING. 


297 


Spiral  reversed  of  the  foot  covering  in  the  heel.  Length, 
four  yards  ;  width,  two-and-a-half  inches.  Fix  by  a  circular 
turn  about  the  ankle,  pass  over  the  dorsum  of  the  foot  to  the 
metacarpo-phalangeal  articulation  ;  make  a  circular  at  that 
point,  and  pass  up  the  foot  by  two  or  three  reversed  turns,  over- 
lapping three-fourths  ;  having  reached  the  top  of  the  instep, 
carry  The  bandage  around  the  x>oint  of  the  heel,  up  over  the  in- 
step, down  around  the  sole  of  the  heel  obliquely,  backward,  and 
upward,  below  the  malleolus,  and  around  the  back  of  the  heel, 
forward  to  the  instep.  Again  pass  under  the  sole  of  the  heel, 
beneath  the  malleolus,  around  the  back  of  the  heel,  and  forward 
to  the  instep.  The  bandage  may  be  pinned  at  any  point,  or 
carried  up  the  leg. 

Spiral  reversed  of  the  lower  extremity.  Length,  twelve 
yards  ;  width,  two-and-a-half  inches.  Fix  at  the  ankle,  pass 
down  over  the  dorsum  of  the  foot,  and  make  a  circular  turn 
about  the  foot  at  the  meta- 
tarso-phalangeal  joint,    pass 


Fig.  79. 


Fig.  80. 


up  the  instep  by  a  spiral,  a 
spiral  reversed,  and  two  or 
three  spica  turns  ;  then  pass 
up  the  leg  by  spiral  turns, 
beginning  to  reverse  as  soon 
as  the  shape  of  the  limb  re- 
quires it.  Cover  the  knee 
with  a  figure-of-eight,  and 
ascend  the  thigh  by  spiral 
reversed  turns.  Overlap  two- 
thirds.  Do  not  make  the 
line  of  the  reverse  over  the  crest  of  the  tibia. 

Figure-of-eight  of  the  knee.  Length,  three 
yards;  width,  two-and-a-balf  inches.  Fix  by 
a  circular  three  or  four  inches  below  the  joint, 
carry  the  bandage  upward  obliquely  over  the 
popliteal  space,  and  make  a  circular  about  the  tliigh,  three  or 
four  inches  above  the  joint,  descend  ohliquely  over  the  popliteal 


Pigure-of-eight  for 
the  knee. 


Spiral  reversed 
of  tlie  lower  ex- 
tremity. 


298 


ESSENTIALS    OF    SURGERY 


space,  and  make  a  circular  about  the  leg,  overlapping  the  first 
turn  upward  two-thirds,  ascend  and  make  a  second  circular 
about  the  thigh,  overlapping  downward  two-thirds.  So  continue 
till  the  joint  is  covered. 

Spica  of  the  groin.  Single  or  double.  Ascending  or  descend- 
ing. Single  ascending.  Length,  ten  yards  ;  width,  two-and-a- 
half  inches.     Fix  around  the  upper  part  of  the  thigh  (if  it  is  the 

left  side,  the  bandage  must 
^ig'  ^1'  be     applied      throughout 

from  right  to  left) ;  carry- 
obliquely  across  pubes, 
lower  part  of  abdomen 
and  crest  of  ilium,  around 
the  back,  and  down  to 
the  starting-point,  passing 
across  the  front  of  the 
thigh,  and  forming  the 
first  spica  turn,  which 
should  be  within  the  mid- 
dle of  the  anterior  surface 
of  the  thigh  ;  repeat  these 
turns,  overlapping  two- 
thirds  in  the  groin,  but 
converging  as  the  bandage 
is  carried  to  the  crest  of 
the  ilium,  till  they  overlie 
in  the  back. 

Bememher    that   in    all 

ascending  spica  bandages, 

the  position  of  the  crossing 

is  determined  by  the  lower 

border  of  the  bandage ;  in 

all  descending  spicas,  the  upper  border  determines  the  position 

of  the  turns.     A  well-applied  spica  should  have  all  the  angles 

of  crossing  exactly  in  line. 

Double  ascending  spica.  Length,  fourteen  yards  ;  width,  two- 
and-a-half  inches.     Fix  by  a  circular  around  the  waist,  carry 


Spica  of  groin.    Single  ascending.    Should 
be  started  around  the  thigh. 


BANDAGING. 


299 


obliquely  downward  across  the  belly,  pubes,  and  left  thigh ; 
around  the  left  thigh,  and  up  to  the  left  iliac  crest,  forming  the 
first  spica  ;  around  the  back,  and  obliquely  down,  across,  and 
around  the  right  thigh,  forming  the  second  spica;  obliquely 
across  the  belly  to  the  left  iliac  crest,  forming  with  the  first 
oblique  abdominal  turn  the  third  spica.  Kepeat  these  turns, 
taking  in  body,  left  thigh,  body,  right  thigh,  and  overlapping 
two-thirds.  There  are  three  sets  of  crossings  :  one  in  the  middle 
line  of  the  belly,  and  one  within  the  middle  line  of  each  thigh. 

Descending  single  and  double  spicas  of  groin.  The  turns  are 
the  same  as  for  the  ascending  spicas,  except  that  the  first  turns 
are  placed  at  the  highest  point  which  it  is  desired  to  cover  by  the 
bandage,  and  the  spicas  are  made  by  the  upper  border  of  the 
bandage. 


Head  Bandages. 

Barton's.     Length,  five  yards  ;  width,  two  inches.     Begin  be- 
hind the  ear  (left  if  standing  behind  the  patient,  right  if  stand- 
ing in  front)  ;    carry   the    roller 
down  under  the  occiput,  and  up  Fig.  82. 

to  a  corresponding  point  behind 
the  other  ear;  thence  directly 
across  the  vertex,  down  the  side 
of  the  face,  under  the  chin,  up  the 
other  side  of  the  face  to  the  ver- 
tex, making  an  intersection  with 
the  former  turn  directly  in  the 
middle  line  ;  then  to  the  point  of 
starting,  around  under  the  occi- 
put, forward  along  the  body  of 
the  jaw,  around  the  sympliysis 
menti,  back  along  the  jaw  on  the 
other  side,  to  tiie  point  of  starting. 
Exactly  repeat  these  turns  three 
times.  Application.  Fracture  of 
jaw. 


Barton's  bandage. 


300 


ESSENTIALS    OF    SUEGEKY. 


Gibson's.    Length, 


five  yards ;  width,   two 
three   vertical   turns. 


inches.      Make 
passing  under 


G-ibson's   bandage.    Vertical 
turn  should  be  made  tirst. 


the  chin,  along  the  sides  of  the  face 
in  front  of  the  ears,  and  over  the  top 
of  the  head  ;  reverse  just  above  the 
ear,  and  make  three  circular  turns 
about  the  forehead  and  occiput ;  as 
the  third  turn  is  completed,  carry  the 
bandage  beneath  the  occiput,  under 
the  ear,  along  the  body  of  the  jaw, 
around  the  symphysis  menti,  andtake 
in  the  front  of  the  chin  and  the  sub- 
occipital region  with  three  turns  ;  re- 
verse beneath  the  occiput,  carry  the 
roller  directly  forward  in  the  middle 
line  to  the  forehead,  pin  all  intersec- 
tions. 
Oblique  of  the  jaw.  Length,  five  yards  ;  width,  two  inches. 
Face  the  patient,  begin  the  bandage  in  the  middle  of  the  fore- 
head and  carry  it  tmmrds  the  injured  side.  Fix  by  a  circular 
fronto-occipital  turn.  Carry  the  roller  obliquely  down  beneath 
the  occiput,  around  the  front  of  the  neck  to  the  angle  of  the 
injured  jaw,  then  up  the  side  of  the  face  (in  front  of  the  ear), 
across  the  vertex,  down  the  side  of  the  head  behind  the  ear  of 
the  sound  side,  under  the  chin,  and  up  again  on  the  injured  side, 
overlapping  the  preceding  turn  forward  three- 
quarters.  The  turns  behind  the  ear  of  the 
sound  side  do  not  overlap. 

Application.  For  fracture  of  the  condyle 
of  the  jaw,  or  fractures  with  marked  lateral 
deformity. 

Recurrent  of  scalp.  Length,  seven  yards  ; 
width,  two  inches.  Fix  by  a  circular  fronto- 
occipital  turn,  then  reverse,  catch  the  point  of 
reverse  with  the  finger  and  pass  directly  from 
occiput  to  brow  across  the  top  of  the  scalp. 
Recurrent  of  scalp.     The  bandage  is  held  in  front  by  an  assistant 


Fig.  84. 


BANDAGING.  301 

and  carried  back  again  overlapping  the  first  recurrent  turn  two- 
thirds  ;  it  is  carried  to  and  fro  in  this  way  till  the  scalp  is  entirely 
covered,  when  the  loops  are  fixed  at  the  sides  by  circular  turns. 

Figure-of-eight  of  the  eye.    Single  and  double. 

Single.  Length,  five  yards  ;  width,  two  inches.  Fix  by  a 
circular  fronto-occipital  turn,  beginning  in  the  middle  of  the 
forehead  and  carrying  the  bandage  away  from  the  injured  eye. 
As  the  bandage  passes  backwards  for  the  third  turn,  carry  it  ob- 
liquely downward  across  the  occiput,  under  the  ear  of  the  affected 
side,  obliquely  upward  over  the  ramus  of  the  jaw  and  the 
affected  eye,  to  the  most  prominent  part  of  the  parietal  bone  ; 
thence  to  the  starting-point  of  the  oblique  turn,  which  is  to  be 
repeated  two  or  three  times  and  fixed  by  a  fronto-occipital 
circular.  This  bandage  may  also  be  applied  by  alternating 
circular  and  oblique  turns,  overlapping  upward  or  downward 
and  making  a  series  of  spicas. 

Double.  Length,  seven  yards  ;  width,  two  inches.  One  eye 
may  be  covered  as  in  the  single  bandage,  then  the  other  in  a 
precisely  similar  manner  ;  or  the  turns  may  alternate  and  over- 
lap, forming  a  series  of  spicas  over  the  bridge  of  the  nose. 

Occipito-facial.  Simply  the  vertical  and  circular  occipito- 
frontal turns  of  the  Gibson  bandage.     Pin  all  intersections. 

Fronto-occipito-cervical  figure-of-eight.  Length,  three  yards ; 
width  two  inches.  Eix  by  a  fronto-occipital  circular  turn,  carry 
obliquely  downward  across  the  occiput  to  the  neck,  around  the 
neck,  obliquely  upward  across  the  occiput,  around  the  forehead, 
obliquely  downward  and  around  the  neck ;  so  continue  till 
the  bandage  is  completed. 

Fronto-occipito-mental  figure-of-eight.  Length,  three  yards  ; 
width,  two  inches.  Apply  as  the  preceding  bandage,  except  that 
the  turn  is  carried  around  the  chin  instead  of  around  the  neck. 

Handkerchiefs. 

Describe  the  handkerchief  bandage. 

Tliis  consists  of  a  tliirty-two  inch  square  piece  of  muslin, 
calico,  or  any  soft  strong  material,  forming  the  square. 


302  ESSENTIALS    OF    SURGERY. 

The  triangle  is  formed  by  bringing  the  two  opposite  angles  of 
the  square  together.  The  parts  of  the  triangle  are,  the  base,  the 
apex  (the  angle  opposite  the  base),  and  the  angles  or  ends. 

The  cravat  is  formed  by  folding  the  triangle  once  or  twice 
from  its  apex  towards  its  base. 

Handkerchief  bandages  receive  a  double  name,  the  first  being 
the  part  to  which  the  base  is  applied,  the  second  the  part  around 
which  the  ends  are  carried. 

The  simple  bandage  is  that  made  up  of  a  single  handkerchief; 
the  compound  bandage  is  that  made  up  of  more  than  one  hand- 
kerchief. 


Handkerchief  Bandages  of  the  Head. 

Occipito-frontal  triangle.  Apply  the  base  to  the  occiput, 
letting  the  apex  fall  over  the  forehead.  Carry  the  two  ends 
forward  around  the  head  and  tie  in  front,  or  cross,  and  pin  at 
the  sides.  Turn  the  apex  up  and  pin  to  the  body  of  the  band- 
age. 

Fronto-occipital  triangle.  As  the  preceding,  except  that  the 
base  is  applied  to  the  forehead,  and  the  apex  falls  over  the 
occiput. 

Bi-temporal  triangle.  As  the  preceding,  except  that  the  base 
is  applied  over  one  temple,  the  apex  falls  over  the  other. 

In  the  choice  of  these  three  bandages,  the  base  is  applied  over 
the  seat  of  injury,  or  where  most  pressure  is  desired. 

Vertico-mental  triangle.  Apply  the  base  to  the  vertex  with 
apex  back ;  carry  the  ends  down  under  the  chin,  and  either  tie, 
or  cross  and  pin.     Bring  the  apex  to  one  side  and  pin. 

Auriculo-occipital  triangle.  This  does  not  conform  to  the 
rule  in  naming.  Place  the  base  in  front  of  the  ear,  apex  back, 
carry  one  end  under  the  chin,  the  other  over  the  top  of  the 
head  and  tie  or  pin  in  front  of  the  ear  on  the  sound  side. 

Square  cap.  Fold  the  handkerchief  so  that  a  quadrilateral  is 
formed,  with  one  border  overlapping  the  other  three  inches. 
Apply  this  quadrilateral  to  the  scalp  with  the  projecting  border 


BANDAGING. 


303 


next  the  surface  and  hanging  over  the  forehead.  Bring  the 
ends  of  the  short  fold  under  the  chin  and  tie.  Fold  back  the 
long  border  exposing  the  forehead,  pull  the  ends  forward  till 
the  bandage  fits  about  the  head,  then  carry  them  back  and  tie 
beneath  the  occiput. 


Fig. 


Beginning  of  square  cap  of  head. 


Square  cap  of  head  completeu. 


Fronto-occipito-labialis  cravat.  Fold  the  triangle  into  a  cravat. 
Place  the  body  upon  the  forehead,  carry  the  ends  back,  cross  at 
the  back  of  the  neck,  and  bring  them  forward,  tying  or  pinning 
over  the  upper  or  lower  hp,  as  required  by  the  injury.  Used  to 
approximate  lip  wounds,  and  to  check  bleeding  from  the  coronary 
arteries. 

Occipito-sternal  triangle  (compound).  Apply  a  sterno-dorsal 
(straight  around)  cravat  about  the  chest.  Flex  the  head  upon 
the  chest  and  apply  the  base  of  a  triangle,  apex  forward  to  the 
occiput,  carry  the  two  ends  down  to  the  sterno-dorsal  cravat  and 
secure.  The  apex  of  the  triangles  may  be  folded  back  and 
pinned.     Used  in  cut  throat  wounds  of  the  neck. 

Parieto-axillaris  triangle  (compound).  Apply  an  axillo- 
acromial  cravat  (around  the  shoulder).  Place  the  base  of  a  tri- 
angle over  the  parietal  eminence  of  the  opposite  side,  carry  the 
ends  around  the  head  and  cross  them  ;  incline  the  head  laterally, 
and  secure  tlie  ends  of  the  triangle  to  the  shoulder  cravat. 

Used  to  approximate  wounds  at  the  .side  of  the  neck. 


301 


ESSENTIALS    OF    SURGERY. 


Handkerchief  Bandages  of  the  Trunk. 

Axillo-cervical  cravat.  Place  the  body  of  the  cravat  in  the 
axilla,  carry  the  ends  over  the  shoulder,  across  each  other,  and 
around  the  neck. 

Used  to  retain  dressings  in  the  axilla. 

Bis-axillary  cravat  (simple).  Place  the  body  in  the  axilla, 
cross  the  ends  over  the  shoulder  and  carry  one  across  the  chest, 
the  other  across  the  back,  to  the  axilla  of  the  opposite  side, 
where  they  are  tied  or  pinned. 

Used  as  the  preceding  bandage. 

Bis-axillary  cravat  (compound).  Place  the  body  of  one  cravat 
in  the  axilla,  carry  its. ends  over  the  shoulder  and  tie  (axillo- 
acromial  cravat).  Place  the  body  of  another  cravat  in  the 
opposite  axilla,  and  carry  the  ends  obliquely  across  the  chest 
and  back  to  the  first  cravat,  tying  them  together  when  one  end 
has  passed  through  the  loop  of  the  first  cravat. 

Used  to  retain  dressings  in  both  axillas. 


Fig.  87. 


Bis-axillo-scapulary  cravat  (simple).    Place  the  body  to  the 

front  of  the  shoulder,  with  the 
lower  end  one-third  longer  than 
the  upper.  Carry  the  upper  end 
over  the  shoulder,  the  lower  end 
under  the  axilla,  obliquely  across 
the  back  to  the  opposite  shoulder, 
around  it,  and  back  to  the  short 
end,  to  which  it  is  tied.  This 
forms  a  posterior  figure-of-eight, 
and  is  used  as  a  temporary  dress- 
ing for  fractured  clavicle. 

Bis  -  axillo  -  scapulary  cravat 
(compound).  Loop  one  cravat 
loosely  about  the  shoulder,   and 

Bis-axillo-scapulary  cravat  (com-      ^^^-  ^^^^^^  thebody  of  the  othercra- 

pound).  vat  in  front  of  the  opposite  shoul- 


BANDAGING. 


305 


Fig.  88. 


der,  carry  the  ends  back,  one  over  the  shoulder,  the  other  through 
the  axilla.  Tie  in  a  single  loose  knot,  carry  one  end  through  the 
loop  of  the  first  cravat,  and  tie  in  a  double  knot. 

Used  to  draw  the  shoulders  forcibly  back,  as  in  fracture  of  the 
clavicle. 

Dorso-bis-axillary  triangle  (compound).  Breakfast  shawl. 
Carry  a  cravat  around  the  chest  and  tie  in  front  (dorso-ster- 
nal).  Place  the  base  of  a  triangle,  apex  down,  on  the  back  of 
the  neck,  carry  each  end  over  the  corresponding  shoulder,  and 
tie  to  the  dorso-sternal  cravat  in  front.  The  apex  is  fastened 
around  the  body  of  the  cravat  behind. 

Used  to  retain  dressings  to  the  shoulder  or  back. 

Mammary  triangle.  Place  the  base  of  the  triangle  under  the 
breast,  and  its  apex  over  the  shoulder  of  the  same  side.  Carry 
one  end  across  the  opposite  side 
of  the  neck,  the  other  under  the 
axilla  of  the  affected  side.  Tie  at 
the  back,  and  secure  the  apex  be- 
neath the  knot. 

Used  to  support  the  breast,  to 
make  pressure,  to  retain  dress- 
ings. 

Scroto-lumbar.  Tie  a  cravat 
about  the  waist.  Place  the  base 
of  a  triangle  beneath  the  scrotum, 
carry  the  two  ends  up  and  secure 
them  to  the  cravat.  Finally  se- 
cure the  apex  by  carrying  it  un- 
der the  cravat,  folding  it  in  front,  and  pinning. 

Used  as  a  suspensory  of  the  scrotum. 

Abdomino-inguinal  (simple).  For  this  bandage  one  long  cra- 
vat may  be  made  Ijy  tyhig  two  together.  Place  the  body  of  the 
cravat  back  of  tlie  thigli  in  such  a  manner  that  one  end  may  be 
two-thirds  longer  than  the  other.  Bring  the  ends  to  the  front, 
cross  over  the  groin,  and  carry  tliem  around  opposite  sides  of 
the  body,  knotting  or  pinnijig  in  front. 
20 


Mammary  triangle. 


306 


ESSENTIALS    OF    SURGERY. 


Fig.  89. 


Used  as  the  spica  of  the  groin,  to  retain 
dressings  on  bubos,  or  make  pressure  upon 
them. 

Abdomino-inguinal  (compound).  Place 
the  centre  of  the  cravat  (three,  knotted  or 
sewed  together)  over  lumbar  vertebrse, 
carry  the  two  ends  forward  on  each  side 
just  below  the  iliac  crests,  obliquely  down- 
ward and  inward  over  the  front  of  the 
groins,  backward  between  the  thighs,  out- 
ward around  each  thigh  to  the  front ;  cross 
over  the  pubes  and  pin  to  the  body  of  the 
Gluteal  triangle.  cravat. 

Gluteal  triangle  (compound).  Tie  a  cravat  about  the  waist. 
Place  the  base  of  a  triangle  obliquely  at  the  gluteal  fold,  and 
tie  the  ends  around  the  thigh.  Carry  the  apex  up  and  under 
cravat,  fold  it  over,  and  pin. 

Used  to  retain  dressings  to  the  gluteal  region. 


Handkerchief  Bandages  of  the  Extremities. 

Palmar  triangle.  Place  the  base  of  the  triangle  on  either  the 
palmar  or  dorsal  surface  of  the  wrist,  fold  the  apex  over  the  hand 
and  back  to  the  wrist,  carry  the  ends  around  the  wrist  and  apex 
and  tie,  fold  the  apex  back,  and  pin  to  the  body  of  the  bandage. 

Triang^ilar  cap  of  the  shoulder.  1.  Place  the  base  on  the 
shoulder,  apex  hanging  down  over  the  arm  ;  carry  the  ends  under 
the  axilla,  across  each  other,  around  the  arm,  taking  in  the  apex, 
and  tie.  Fold  the  apex  upward,  and  pin  to  the  body  of  the 
bandage. 

2.  Place  the  base  of  the  bandage  on  the  upper  part  of  the  arm, 
with  the  apex  covering  the  shoulder ;  carry  the  ends  around  the 
arm,  across  each  other  in  the  axilla,  and  up  around  the  shoulder, 
taking  in  the  apex.  Fold  the  apex  down  and  pin.  Used  to  re- 
tain dressings  to  the  upper  part  of  the  arm  or  shoulder. 


BANDAGING. 


307 


Triangular  cap  of  a  stump.  Place  the  base  under  the  stump, 
carry  the  apex  over  its  end.  Secure  the  apex  by  carrying  the 
ends  around  the  hmb,  and  pinning  or  knotting.  Fold  the  apex 
up,  and  pin  to  the  body  of  the  bandage. 

Cervico-brachial  triangle.  SUng  of  the  arm.  Place  the  base 
of  a  triangle  at  the  wrist  of  the 
flexed  forearm,  carry  the  ends 
over  the  shoulders,  around  the 
back  of  the  neck,  and  tie.  Draw 
the  apex  back  beyond  the  elbow, 
fold  it  posteriorly,  and  pin  it  in 
this  position.  If  the  triangle  is 
not  long  enough,  a  cravat  may  be 
tied  loosely  around  the  neck,  and 
'  the  ends  of  the  triangle  knotted 
in  this. 

Metatarso-inalleolar     cravat. 

Place  the  body  obliquely  across 

the  back  of  the  foot,  carry  one 

end  around  the  foot,  the  other  around  the  ankle,  and  tie  in  front, 

over  the  back  of  the  foot. 

Malleolo-phalangeal  triangle.  Place  the  base  in  the  hollow 
of  the  foot.  Fold  the  apex  around  the  toes  and  in  front  of  the 
ankle-joint.  Carry  the  ends  around  the  foot,  cross  on  the 
dorsum,  and  continue  around  the  malleoli ;  then  back  to  the 
dorsum,  securing  here,  or  continuing  to  the  side  and  pinning. 

Cervico-tibial  triangle.  Carry  a  cravat  from  the  top  of  the 
shoulder  of  the  sound  side  to  the  axilla  of  the  injured  side,  around 
the  body  to  the  point  of  starting,  and  tie.  Flex  the  leg  and  place 
the  base  of  a  triangle  on  the  tibia  just  above  the  ankle.  Carry 
the  ends  up  and  tie  through  the  cravat.  Bring  the  apex  around 
the  knee,  and  pin  to  the  body  of  the  handkerchief.  Used  to  sup- 
port the  leg  when  it  is  fractured,  and  the  patient  is  reciuired  to 
walk. 

Figure-of-eight  of  the  knee.  Place  the  body  of  the  cravat  just 
above  the  patella,  carry  the  ends  back,  cross  in  the  popliteal 


Oervico-brachial  triangle. 


308  ESSENTIALS    OF    SUEGERY. 

space,  bring  them  forward  just  below  the  patella,  and  tie.    Used 
to  approximate  the  fragments  of  a  fractured  patella. 

Tarso-patellar  cravat.  Place  one  cravat  as  a  figure-of-eight 
of  the  knee,  loop  another  cravat  around  the  foot,  just  anterior 
to  the  ankle ;  catch  the  body  of  the  third  cravat  through  this 
loop,  and  carry  its  ends  under  both  the  lower  and  upper  seg- 
ments of  the  figure-of-eight,  and  secure  by  pinning.  Used  to 
approximate  the  fragments  of  a  broken  patella. 

Tibial  cravat.  Place  the  body  obliquely  across  the  calf,  carry 
the  ends  around  the  leg,  one  below  the  patella,  the  other  above 
the  malleoli.     Used  to  retain  dressings. 

Barton's  cravat.  Place  the  body  of  the  cravat  around  the 
point  of  the  heel,  with  the  end  corresponding  to  the  outer  side 
of  the  foot  one-third  longer  than  the  other.  Hold  the  inner  end 
(short)  parallel  with  the  foot,  while  the  long  end  is  carried  across 
the  instep,  turned  once  around  the  inner  end,  back  under  the 
sole  of  the  foot,  and  looped  around  itself  as  it  crosses  obliquely 
over  the  instep.  The  two  ends  are  knotted,  drawn  upon^  and 
the  cravat  so  arranged  that  traction  exerts  equal  pressure  upon 
dorsum  and  heel.     Used  to  make  extension  for  fractured  femur. 


INDEX 


ABSCESS,  acute,  27 
bone,  171 

Brodie's,  171 

chronic,  29 

diploe,  78 

follicular,  212 

mammary,  253 

mediastinal,  134 

periosteal,  169 

periurethral,  213 

residual,  30 

tubercular,  29 
Amputation,  282 

Garden's,  286 

Ch opart's,  284 

Dupuytren's,  289 

Gritti's,  286 

Hey's,  284 

in  coxalgia,  165 

in  fracture,  110 

in  gangrene,  43 

in  gunshot  wounds,  71 

Larrey's,  289 

Lisfranc's,  284 

Pirogoflf's,  284 

Sedillot's,  285 

Syme's,  285 

Teale's,  283 
Anaesthetics,  258 
Anchylosis,  108 

in  coxalgia,  165 

in  fracture,  121 
Aneurism,  anastomotic,  244 

arterio-venous,  74 

cirsoid,  244 

classification,  245 

traumatic,  74 

varicose,  74 
Aneurisinal  varix,  74 
Angioma,  244 

Antiseptic  treatment,  44,  66 
Anus,  artificial,  187 

diseases  of,  198 

nHBure,  202 


Anus,  fistula,  202 

malformation,  198 
pruritus,  205 
ulceration,  203 

Arthrectomy,  278 

Arthritis,  161 

gelatinous,  162 
rheumatoid,  167 
strumous,  162 

of  hip-joint,  163 
of  knee-joint,  166 


BALANITIS,  212 
Balano-posthitis,  212 
Bandages,  handkerchief,  31 
Barton's,  308 
roller,  290 

Barton's,  299 
Desault's,  294 
Gibson's,  300 
Velpeau's,  293 
Barton's  cravat,  308 
fracture,  122 
head  bandage,  299 
Bed-sore,  41 
Bites,  72 

Bladder,  atony,  229 
bar  at  neck,  226 
exstrophy,  227 
inflammation,  228 
paralysis,  229 
rupture,  227 
tumors,  227 
Bone,  diseases,  169 
syphilis,  173 
tubercle,  173 
Brodie's  abscess,  171 
Bronchotomy,  250 
Bronchus,  foreign  body,  250 
Bubo,  d'eml)l6e,  211 
gonorrhceal,  213 
j)riinary,  21 1 
sypliililic,  206 

(  309  ) 


310 


INDEX. 


Bunion,  256 
Burns,  102 
Bursa,  dropsy,  256 
Bursitis,  256 


/^ALCULT,  vesical,  233 
\J     Callus,  109 
Canal,  femoral,  192 

inguinal,  189 
Canerum  oris,  40 
Carbuncle,  42 
Caries,  172 
Catheter,  Mercier,  231 

olive-pointed,  220 

prostatic,  231 

railroad,  220 
Cellulitis,  52 
Chancre,  206 
Chancroid,  210 
Chilblain,  249 
Chloroform,  259 
Chordee,  214 
Cicatrization,  31 
Circumclusion,  63 
Clap,  211 
Cleft  palate,  255 
Club-foot,  254 
Cock's  perineal  section,  222 
Cold,  effects  of,  249 
Colles's  law,  210 
Compression,  cerebral,  84 
Concussion,  cerebral,  83 

of  lung,  94 
Contusion,  abdominal,  96 

cerebral,  83 

of  cranium,  78 

of  scalp,  77 
Counter-irritation,  23 
Cowperitis,  213 
Coxalgia,  163 

diagnosis,  166 
Cupping,  22 
Cystitis,  228 
Czerny's  suture,  99 


DELIRIUM  tremens,  46 
Diffused  aneurism,  74,  245 
Dilatation  of  stricture,  220 
Discharge,  urethral,  215 
Dislocation,  see  Luxation 
Dissecting  aneurism,  245 
wound,  71 


Double  inclined  plane,  130 
Dressing,  Lister's,  67 
Dupuytren's  splint,  133 


EMPHYSEMA,  94 
Encephalitis,  86 
Enterocele,  180 
Eutero-epiplocele,  180 
Epididymitis,  213 
Epiplocele,  180 
Epispadia,  217 
Erysipelas,  50 
Ether,  258 
Excision,  278 

ankle-joint,  281 

elbow-joint,  279 

hip-joint,  279 

in  coxalgia,  165 

knee-joint,  280 

shoulder-joint,  278 

wrist-joint,  279 
Extension  apparatus,  129 
Extravasation,  intracranial,  81 

of  urine,  223 


F^CES,  impaction  of,  204 
False  joint,  111 

passage,  219 
Fever,  hectic,  50 

inflammatory,  48 
pysemic,  49 
septicsemic,  48 
traumatic,  47 
Fissure,  anal,  202 

of  Rolando,  88 
Fistula,  anal,  202 
fsecal,  187 
salivary,  90 
Forcipressure,  62 
Foreign  body  in  brain,  87 
in  bronchus,  250 
in  lai'ynx,  250 
in  oesophagus,  252 
Fractures,  105 

anaesthetics  in,  112 
Barton's,  122 
clavicle,  114 
coccyx,  126 
Colles's,  122 
compound,  108 
delayed  union  in,  110 
delirium  tremens  in,  136 


INDEX. 


311 


Fractures,  diagnosis,  107 

femur,  126 

fibula,  132 

humerus,  117 

hyoid  bone,  114 

inferior  maxilla,  113 

larynx,  114 

metacarpus,  125 

nasai  bone,  112 

non-union  in,  110 

patella,  131 

pelvis,  125 

phalanges,  125 

Pott's,  132 

radius,  122 

ribs,  134 

sacrum,  126 

scapula,  116 

skuli,  78 

Smith's,  123 

sternum,  134 

superior  maxilla,  113 

T,  117 

tarsus,  134 

tibia,  132 

treatment,  107 

ulna,  121 

ununited,  110 

vertebrae,  135 

vicious  union,  111 
Fracture-box,  133 
Frost-bite,  249 
Furuncle,  41 


GANGLION,  256 
Gangrene,  38 

Germ  theoiy,  44 

Glanders,  55 

Gleet,  215 

Gonorrhoea,  acute,  211 
chronic,  215 
in  women,  216 

Granulations,  31 

Gumma,  208 


HEMATOCELE,  239 
Ilaematuria,  220 
ITiemopliilia,  177 
Ilietnothoi-ax,  93 
Hare-lip,  255 
Hemorrhage,  57 
arrest  of,  58 


Hemorrhage,  bladder,  230 

kidney,  230 

urethra,  230 
Hemorrhoids,  199 
Hernia,  179 

cerebri,  87 

classification,  180 

congenital,  188,  191 

crural,  192 

encysted,  188,  191 

femoral,  192 

incarcerated,  182 

infantile,  188,  191 

inflamed,  182 

inguinal,  188 

irreducible,  181 

Littre's,  184 

of  lung, 94 

reducible,  180 

strangulated,  183 

umbilical,  194 
Herniotomy,  186 
Hutchinson's  teeth,  209 
Hydrarthrosis,  161 
Hydrocele,  238 
Hydrophobia,  54 
Hypertrophy  of  prostate,  225 
Hypospadia,  217 


IMPACTED  fseces,  204 
X    Imperforate  anus,  198 
Impermeable  stricture,  223 
Incarcerated  hernia,  182 
Incontinence,  urinary,  233 
Inflammation,  17 

intracranial,  86 
Ingrowing  toe-nail,  257 
Internal  strangulation,  197 
Intestinal  obstruction,  196 
Intussusception,  197 


"IZYPHOSIS,  178 


LAPAROTOMY,  100,  198 
Laryngotomy,  251 
Larynx,  foreign  body,  250 
Leeching,  23 
Lembert's  suture,  99 
Ligament,  coraco-humeral,  143 
Y,150 


812 


INDEX, 


Ligamentous  unioB,  135 
Ligations,  261 

anterior  tibial,  276 

axillary,  268 

brachial,  269 

common  carotid,  263 

dorsalis  pedis,  277 

external  carotid,  264 

external  iliac,  272 

facial,  265 

femoral,  27*2 

internal  mammary,  268 

lingual,  265 

occipital,  266 

palmar  arches,  271 

popliteal,  274 

posterior  tibial,  275 

radial,  270 

subclavian,  267 

temporal,  266 

ulnar,  271 
J^itholapaxy,  235 
Lithcaysis,  235 
Lithotomy,  235 
Llthotrity,  235 
Localization,  cerebral,  87 
Loose  bodies  1^  joints^  167 
Lordosis,  178 
Luxations,  137 

astragalus,  156 

carpus,  148 

classification,  13T 

clavicle,  141 

complications,  139 

femur,  150 

humerus,  143 

jaw,  140 

metacarpus,  149 

old,  139 

patella,  155 

phalanges,  149 

radius, 148 

ribs,  141 

scapula,  143 

semilunar  cartilages,  155 

tarsus,  156 

tibia,  154 

treatment,  139 

lilpa,  147 


MALIGNANT  pustule,  55 
Meningitis,  86 
Micro-organisms,  44 


Mortification,  38 
Mucous  patch,  207 

N^VUS,  capillary,  244 
venous,  244 
Necrosis,  172 
Nodes,  periosteal,  169 
Noma  pudendi,  41 


rr^SOPHAGUS,  foreign  body,  252 

Uli     stricture,  252 

Onvchia,  257 

Ophthalmia,  213 

Orchitis,  240 

Osteitis,  170 

deformans,  170 

rarefying,  170 
Osteomalacia,  174 
Osteomyelitis,  170 
Osteoporosis,  170 


PAGET'S  disease,  253 
Paraphimosis,  212 
Paronychia,  257 
Passage  of  catheter,  219 
Perineal  section,  222 
Peritonitis,  97 
Periostitis,  169 

osteoplastic,  169 
Pernio,  249 
Phimosis,  212 
Phlebitis,  242 
Piles,  199 
Plaster  jacket,  176 
Plastic  lymph,  18 
Pneumothorax,  94 
Pneumotomy,  95 
Pott's  disease,  174 

puffy  tumor,  78 
Poupart's  ligament,  190 
Prolapsus  of  lung,  94 

recti,  201 
Prostatitis,  224 
Pruritus  ani,  205 
Pupil  in  brain  ipjury,  85 
Pus,  19 
Pyaemia,  49 


RACHITIS,  176 
Eectum,  diseases  of,  198 


INDEX. 


313 


Rectum,  polyp,  204 

prolapse,  201 

stricture,  203 

ulceration,  203 

villous  tumor,  205 
Resection,  278 
Retention  of  urine,  230 
Retrod usion,  62 
Rheumatism,  gonorrhoeal,  213 
Rickets,  176 
Ring,  abdominal,  189,  190 

femoral,  193 
Rupture  (see Hernia),  179 

of  viscera,  96 


SALIVATION,  26 
Saphenous  opening,  193 
Sarcocele,  240 

Say  re's  fracture-dressing,  115 
Scalds,  102 
Scalp,  layers,  75 
wounds,  77 
Scoliosis,  178 
Scrofula,  177 
Septicaemia,  48 
Shock,  45 

ether  in,  260 
Sinus,  30 
Skin  grafts,  37 
Spine,  curvature,  177 
Splints,  coxalgia,  165 
Bond's,  124 
Dupuytren's,  133 
Sprain,  158 

fracture,  158 
of  back,  159 
Staphyloplasty,  255 
Staphylorraphy,  255 
Stimulants,  25 
Stings,  72 

Stone  in  bladder,  233 
Strapping  chest,  135 
Stricture,  urethra,  217 
Struma,  177 
Sutures,  65 
Synovitis,  160 

gonorrhcjeal,  213 
Syphilis,  206 


rpALIPES,  254 
i     Tapping  abdomen,  100 
bladder,  233 


Tapping  pericardium,  95 

pleura,  95 
Taxis,  184 
Tenosynovitis,  256 
Tetanus,  52 
Thrombosis,  242 
Torsion,  61 
Torsoclusion,  62 
Trachea,  foreign  body  in,  250 
Tracheotomy,  251 
Transfusion,  59 
Trephining,  89 
Triangles  of  neck,  262 
Trophic  changes,  75 
Tubercle,  173 
Tumors,  breast,  253 

ULCERATION,  31 
Ulcers,  32 
Uranoplasty,  255 
Urethra,  211 

deformities,  217 
rupture,  223 
stricture,  217 
Urethrotome,  221 
Urethrotomy,  221 


VARICOCELE,  240 
Varicose  aneurism,  74 
veins,  243 
Varix,  243 

aneurismal,  74 
arterial,  244 
Veins,  diseases  of,  242 

varicose,  243 
Venereal  disease,  206 
Vesication,  24 
Volvulus,  197 

WALLERIAN  degeneration,  74 
White  swelling,  162 
hip-joint,  163 
knee-joint,  166 
Wounds,  44 

abdomen',  95 
arteries,  73 
chest,  92 
classification,  68 
contused,  69 
dissecting,  72 
face,  90 


314 


INDEX. 


Wounds,  gunshot,  70 
incised,  69 
joints,  159 
lacerated,  69 
neck,  91 
nerves,  75 
oesophagus,  92 


Wounds,  poisoned,  71 
punctured,  69 
scalp,  77 
trachea,  92 
veins,  75 
Y  ligament,  151 


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of  Philadelphia ;  Editor  of  "  Cyclopxtlia  of  the  Diseases  of  Children";  Author  of 

Keating 's  Unabridged  Medical  Dictionary,"  etc,  etc.  A  compact,  concise,  com 
j)rehensive  and  convenient  lexicon  of  medical  terminology.  Invaluable  to  the 
student  of  medicine.     Price,  cloth,  75  cents  ;  morocco  tucks,  $1. 


%♦  For  sale  by  all  booksellers.    Mailed  free  on  receipt  of  price 
to  any  post  oflSce  address  in  the  United  States  or  Canada. 


SAUNDERS'  QUESTION-COMPENDS. 


OPINIONS  OF  THE  PRESS. 


illy  itxluK  '  ,  , 


•'-.t  e.xcellent  addition  ?.. 

:    u  iii    i.f-   ..f  ,....,.t  ,. , 

lilt 

I  ins  icuUci,^  ihc  Iju.-U   :  ■  it-aU  lha«»  iitu«i  oouitietids  tbaUBdOv '(li<^- 

ifitly  to  its  vttlue." 

\  trad  from  tkt  Neiv   \'ark  Mtai^ai  JonrHal,  May,  1890. 

Stelwa>Ton'8  Dl»eiwcs  of  the  >kiu.    ••  \Vi-  air  ii,.i, 
another  excellent   hook  011    I '  1 

entitled  "Kssejitlals   of  l»..i 
which  it  is   writien.    T1)h  .   , 

jn-^t  such  a  book  is   nieileU.     W  c  ;iic  j.Uii-cvl  \\  jili  ibe  buiidB«*ii  icVr 

of  the   book,  with   its  dear  type  and  good  paper,    and  would    -  -nu 

iiieiul  tlu'  wodiK-rs  lli;it  iHu-triid.-  lh<'  ^•xt.■ 


'•  An  ex;uniiuiliuu  ot  ihu  uiunuul?  beluie  u^  cannot  fail  lo  convince  one 
1  hat  the  aathoi.s  have  done  their  work  in  a  satl!»factory  manner. 

"Dr.  Stelwagon's  Essentials  of  Diseases  of  the  Skin  is  an  af1"i^-'i'i«  ^ou)- 
pend  of  our  knowledge  of  DenuaiolojjTv.    The  author's  experien  >jer 

hasenabled   him  to  formulate  questions  covering  all  essential  p<  the 

answers  ai-e  comprehensive  with  sufficient  accuracy  of  detail  to  L^  v^iily 

intelligible.  Of  especial  value  and  completeness  is  the  therapeutical  part  of 
the  work.  • 

„()^.,  ^0. -.--^°-'-^-"  *^^-^-T^"^^"^.***^^  of  the  Urine,  has  given  an  account  of  the- 


Dr.  Wolff  in  the  Examination  of  the  ITrine.  has  given 

aal  and  pathological  constituents  of  the  urine  and  a  resumf.  of  the  recent  and 
most  improved  methods  for  its  chemical  and  microscopical  examination.  The 
importance  of  a  knowledge  of  urinologv  and  urinalvsis  to  the  student  ot  derma- 
loiogy  and  genito-urinary  diseases  cannot  too  stronglv  be  insisted  on." 

•-L>r.  Craigin   in  his  Essentials  of  Gynaecologv  embi-aces  manv  morbid  eon- 


fonorrhceal  inflammation." 

Extract  from-  Boston  Medical  and  Surgical  yournal.  May  i,  1890. 

"Craigin's  Gynaecology,  a  little  book  that  does  contain  the  essentials  of  ffynw- 
oology  and  may  be  recommended  to  the  student  as  a  safe  and  useful  guide  to  him 
in  his  studies."  6"  ^^^  iw  mm 


SAUNDERS'  QnESTION-GOMPENDS. 

OPINIONS  OF  THE  PRESS. 

Extracts  from  Annals  of  Surgery,  June,  1889. 

"  They  may  be  used  to  no  little  advantage  by  the  practitioner,  in  presenting  the 
main  facts  of  his  professional  work,  in  a  suitable  form  for  ready  reference  and  com- 
plete classification.  The  form  of  Questions  and  Answers  is  peculiarly  qualified  to 
secure  definiteness  of  information.  Dr.  JSTancrede  has  given  us  a  work  far  more  exten- 
sive in  its  character  than  anything  of  the  kind. 

The  Medical  Student  who  shall  have  mastered  its  contents,  will  certainly  have 
acquired  all  the  essential  points  of  Anatomy." 

"The  Essentials  of  Physiology  are  most  clearly  and  comprehensively  outlined  by 
Dr.  Hare," 

Wolff's  Chemistry. — ''The  questions  are  distinctly  stated,  and  the  answers, 
'framed  with  marked  clearness,  are  fully  up  to  the  times." 

"Martin's  Surgery,  comprehensive  in  scope;  it  is  an  unusually  satisfactory  con- 
-densation." 

AsHTOx's  Obstetrics. — "The  book  j^resents  all  the  essentials  of  its  subjects,  and 
much  other  valuable  matter." 

Extracts  from  University  Medical  Magazine. 

Martin's  Surgery.-^" The  most  pronounced  opponent  of  the  system  of  '  Quizzing' 
in  vogue  at  the  present  4ay,  could  find  no  ground  for  objections  to  this  excellent  little 
book,  which  cleverly  combines  all  the  merits  of  condensation,  while  avoiding  the  errors 
of  superficiality  and  inaccuracy  with  which  such  Compend«  commonly  abound.  It  is  a 
pleasure  to  be  able  to  recornm^nd  the  book  absolutely  and  without  reservation,  as  thor- 
-oughly  fulfilling  the  purpose  for  which  it  was  written,  and,  so  far  as  Surgery  is  con- 
cerned, decidedly  the  best  of  its  kind  with  which  we  are  acquainted." 

Naxcrede^s  Anatomy. — "To  learn  Anatomy  is  not  merely  to  remember  the  names 
of  muscles,  arteries  and  nerves,  but  to  study  their  origin  and  insertions,  their  course 
and  relations,  and  their  distribution.  Dr.  Nancrede  has  kept  this  necessity  constantly 
in  mind,  and  the  student  who  masters  the  details  of  this  little  book  in  connection  with 
conscientious  work  in  the  dissecting  room,  will  find  it  a  help  for  which  his  tired  mem- 
ory will  often  sincerely  give  thanks.  The  questions  have  been  wisely  selected,  the 
answers  are  accurate  and  concisely  constructed,  but  still  with  sufficient  detail  to  free 
them  from  the  criticism  that  they  are  merely  lists  of  names." 

Extract  from  New  York  Medical  Eecord,  May,  1889. 

'"  Saunders'  Series  of  Student's  Manuals,  arranged  in  the  form  of  Questions  and 
■A-nswers,  are  concise,  without  the  omission  of  any  essential  facts.  Handsome  b.'nding, 
good  paper  and  clear  type  increase  their  attractiveness." 

Extract  from  St.  Joseph's  Medical  Herald,  March,  1889. 

"  Wolff's  Chemistry. — A  little  book  that  explains,  clearly  and  simply,  the  most 
difficult  points  in  Medical  Chemistry,  so  that  this  need  no  longer  be  the  great  bugbear 
of  a  medical  student's  efforts." 


^> 


37 


MPENDS. 


Aox-Vv-C^ 


,1889. 

|te  for  the  Student  that 
men  who,  being  them- 
e  most  elucidation,  and 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  37  IV136  1890  C.1 

Essentials  of  surgery 


2002202140 


urgery, 

a  for  students ;    its 

1889. 

rk  upon  Pathology 
;ady  comprehension 
ieal  literature.  All 
t  recent  views  as  to 
and  teacher  skilled 
comprehension,  are 
refer  to  the  more 
needed,  but  a  book 
r  to  the  profit  and 


Luary,  1890. 
ractive  shape,  and 
specimen  of  book 


,  1889. 

at  has  come  under 
er  valuable." 

} 

Extract  from  Southern  California  Practitioner,  March,  1889. 

i  o.v's  Obstetrics.—"  Dr.  Ashton's  little  work  is  a  marvel  of  condensation  and 
ipleteness.  It  will  be  of  unquestionable  value  to  the  practitioner  in  serving  to 
ill  some  of  the  multitudinous  facts  in  the  obstetrical  art,  which  will  frequently 
ipe  the  most  capacious  memory." 

Extract  from  Southern  Clinic,  January,  1890. 
Morris'  Mateuia  Medica.— "The  arrangement  and  subject-matter  of  this  book 
■■i  nothing  to  be  asked  for,  either  for  the  etudent  or  medical  practitioner.     It  is  a 
v.un.xhh  cubstitute  for  larger  and  more  expensive  works." 


